Provider Demographics
NPI:1831146117
Name:KOGAN, FREDERICK JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:JOSEPH
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 1:14410 N. 14TH ST.
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-4446
Mailing Address - Country:US
Mailing Address - Phone:602-375-1433
Mailing Address - Fax:
Practice Address - Street 1:6707 N 19TH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-1104
Practice Address - Country:US
Practice Address - Phone:602-249-4750
Practice Address - Fax:602-249-4814
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12265207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ241703Medicaid
AZZWCKJD08Medicare PIN
AZZ10WCFGW01Medicare PIN
AZ100004568Medicare PIN
AZ241703Medicaid