Provider Demographics
NPI:1780652040
Name:KOGAN, SETH A (MD)
Entity Type:Individual
Prefix:
First Name:SETH
Middle Name:A
Last Name:KOGAN
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 1:790 E WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-2735
Mailing Address - Country:US
Mailing Address - Phone:562-595-4014
Mailing Address - Fax:562-595-7262
Practice Address - Street 1:790 E WILLOW ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2735
Practice Address - Country:US
Practice Address - Phone:562-595-4014
Practice Address - Fax:562-595-7262
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG49334174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA92892Medicare UPIN