Provider Demographics
NPI:1629064555
Name:COGEN, KENNETH ALAN (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ALAN
Last Name:COGEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 587
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83303-0587
Mailing Address - Country:US
Mailing Address - Phone:208-814-7400
Mailing Address - Fax:208-814-7491
Practice Address - Street 1:746 N COLLEGE RD
Practice Address - Street 2:SUITE D
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3486
Practice Address - Country:US
Practice Address - Phone:208-814-7230
Practice Address - Fax:208-734-1178
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM10054207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807994200Medicaid
IDP00704141OtherMCRR
ID11002961Medicare PIN
A04284Medicare UPIN