Provider Demographics
NPI:1528007416
Name:KELLOGG, DEATRICE LUMAE (MD)
Entity Type:Individual
Prefix:
First Name:DEATRICE
Middle Name:LUMAE
Last Name:KELLOGG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 S. NATIONAL AVE
Mailing Address - Street 2:STE. 540
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5284
Mailing Address - Country:US
Mailing Address - Phone:417-269-9220
Mailing Address - Fax:417-269-9229
Practice Address - Street 1:3525 S. NATIONAL #207
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7315
Practice Address - Country:US
Practice Address - Phone:417-269-9220
Practice Address - Fax:417-269-9229
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012030150207Q00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00302605OtherRR MEDICARE
191723OtherGHP
IL08232095OtherBCBS
7300116OtherUHC
P00302605OtherRR MEDICARE
IL212557Medicare PIN