Provider Demographics
NPI:1861677437
Name:KOGAN, JACOB (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:KOGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:YACOV
Other - Middle Name:
Other - Last Name:KOGAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:7001 MAIN CAMPUS DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-8609
Mailing Address - Country:US
Mailing Address - Phone:203-804-1038
Mailing Address - Fax:
Practice Address - Street 1:55 FOGG RD
Practice Address - Street 2:
Practice Address - City:SOUTH WEYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02190-2432
Practice Address - Country:US
Practice Address - Phone:781-340-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-02
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2340652084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology