Provider Demographics
NPI:1568762995
Name:CLOGG, KEVIN WILLIAM (OD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:WILLIAM
Last Name:CLOGG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:2300 BUFFALO RD
Mailing Address - Street 2:BLDG 700
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14624-1367
Mailing Address - Country:US
Mailing Address - Phone:585-328-0153
Mailing Address - Fax:585-328-0158
Practice Address - Street 1:2300 BUFFALO RD
Practice Address - Street 2:BLDG 700
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14624-1367
Practice Address - Country:US
Practice Address - Phone:585-328-0153
Practice Address - Fax:585-328-0158
Is Sole Proprietor?:No
Enumeration Date:2010-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007652-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist