Provider Demographics
NPI:1689814634
Name:KOGAN, DEREK B (DC, LAC)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:B
Last Name:KOGAN
Suffix:
Gender:M
Credentials:DC, LAC
Other - Prefix:DR
Other - First Name:DEREK
Other - Middle Name:B
Other - Last Name:KOGAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC, LAC
Mailing Address - Street 1:6055 LEHMAN DR STE 105
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-5486
Mailing Address - Country:US
Mailing Address - Phone:719-246-9276
Mailing Address - Fax:
Practice Address - Street 1:6055 LEHMAN DR STE 105
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-5486
Practice Address - Country:US
Practice Address - Phone:719-246-9276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-04
Last Update Date:2016-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2151171100000X
CO7357111N00000X
CA13090171100000X
CA33225111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No111N00000XChiropractic ProvidersChiropractor