Provider Demographics
NPI:1083657084
Name:KELLOGG, JEFFREY L (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:L
Last Name:KELLOGG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 PIERCE ST
Mailing Address - Street 2:STE102
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51101-1061
Mailing Address - Country:US
Mailing Address - Phone:712-226-2600
Mailing Address - Fax:712-226-2605
Practice Address - Street 1:4545 SERGEANT RD
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51106-4706
Practice Address - Country:US
Practice Address - Phone:712-274-2400
Practice Address - Fax:712-274-1484
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA02201207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1098830Medicaid
SD7764992Medicaid
IA70220OtherWELLMARK OF IA
IA1098830Medicaid
IAI21270Medicare PIN