Provider Demographics
NPI:1689700494
Name:KOGER, KIM EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:EDWARD
Last Name:KOGER
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 1:4600 MILITARY TRAIL
Mailing Address - Street 2:SUITE 202
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458
Mailing Address - Country:US
Mailing Address - Phone:561-748-1565
Mailing Address - Fax:561-748-1568
Practice Address - Street 1:210 JUPITER LAKES BLVD
Practice Address - Street 2:BLDG 5000 SUITE 202
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-7191
Practice Address - Country:US
Practice Address - Phone:561-748-1565
Practice Address - Fax:561-748-1568
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL75895171000000X
FLME75895208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL43728Medicare UPIN
43728AMedicare ID - Type Unspecified
G80384Medicare UPIN