Provider Demographics
NPI:1376561027
Name:KELLOGG, CHERYL L (MD)
Entity Type:Individual
Prefix:DR
First Name:CHERYL
Middle Name:L
Last Name:KELLOGG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CHERYL
Other - Middle Name:L
Other - Last Name:PATTERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:30100 TOWN CENTER DR
Mailing Address - Street 2:SUITE O #437
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-2064
Mailing Address - Country:US
Mailing Address - Phone:949-342-1780
Mailing Address - Fax:949-342-1786
Practice Address - Street 1:30131 TOWN CENTER DR
Practice Address - Street 2:SUITE 204
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-2034
Practice Address - Country:US
Practice Address - Phone:949-342-1780
Practice Address - Fax:949-342-1786
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC050266174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13226AOtherMEDICARE GROUP NUMBER
CAZZZ47948ZOtherBLUE SHIELD
CAC050266OtherSTATE LICENSE #
CAE93393Medicare UPIN
CAWC50266BMedicare PIN