Provider Demographics
NPI:1639287899
Name:KOGAN, IRINA (MD)
Entity Type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:KOGAN
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 1:464 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02494-1227
Mailing Address - Country:US
Mailing Address - Phone:781-449-5170
Mailing Address - Fax:
Practice Address - Street 1:464 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02494-1227
Practice Address - Country:US
Practice Address - Phone:781-449-5170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA203536207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9727540Medicaid
MAA31366Medicare ID - Type Unspecified