Provider Demographics
NPI:1932109295
Name:WOGENSEN, KENNETH KARL (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:KARL
Last Name:WOGENSEN
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 1:1015 N FIRST AVENUE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-2534
Mailing Address - Country:US
Mailing Address - Phone:626-566-2866
Mailing Address - Fax:626-566-2850
Practice Address - Street 1:1015 N FIRST AVENUE
Practice Address - Street 2:SUITE A
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006-2534
Practice Address - Country:US
Practice Address - Phone:626-566-2866
Practice Address - Fax:626-566-2850
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG528702084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAW2823905OtherDEA
CA00G528700Medicaid
A52373Medicare UPIN