Provider Demographics
NPI:1578509444
Name:KELLOGG, WILL (MD)
Entity Type:Individual
Prefix:DR
First Name:WILL
Middle Name:
Last Name:KELLOGG
Suffix:
Gender:M
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:PO BOX 97115
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98497-0115
Mailing Address - Country:US
Mailing Address - Phone:253-588-7911
Mailing Address - Fax:253-365-6299
Practice Address - Street 1:1901 S UNION AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-1702
Practice Address - Country:US
Practice Address - Phone:360-337-7880
Practice Address - Fax:360-337-7881
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-21
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00034368207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0127354OtherLABOR& INDUSTRIES
WA1107614Medicaid
WA8935812OtherCRIME VICTIMS
WAKE5497OtherREGENCE BLUESHIELD
WA8935812OtherCRIME VICTIMS