Provider Demographics
NPI:1245379627
Name:KOGAN, WALDEMAR (LMT)
Entity Type:Individual
Prefix:MR
First Name:WALDEMAR
Middle Name:
Last Name:KOGAN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:467 LAKE HOWELL RD
Mailing Address - Street 2:SUITE103
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-5922
Mailing Address - Country:US
Mailing Address - Phone:407-927-4450
Mailing Address - Fax:407-628-0323
Practice Address - Street 1:467 LAKE HOWELL RD
Practice Address - Street 2:SUITE 103
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-5922
Practice Address - Country:US
Practice Address - Phone:407-927-4450
Practice Address - Fax:407-628-0323
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA7323225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist