Provider Demographics
NPI:1477998839
Name:KELLOGG, CLINT W (DO)
Entity Type:Individual
Prefix:
First Name:CLINT
Middle Name:W
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 1:3600 AMRON CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65202-1918
Mailing Address - Country:US
Mailing Address - Phone:573-874-1616
Mailing Address - Fax:573-875-0300
Practice Address - Street 1:3600 AMRON CT
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65202
Practice Address - Country:US
Practice Address - Phone:573-874-1616
Practice Address - Fax:573-875-0300
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-30
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ9396207W00000X
MO2018010581207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology