Provider Demographics
NPI:1184758534
Name:KOGER, STEPHEN A (OT)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:A
Last Name:KOGER
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1170 CORPORATE DR W STE 102
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76006-6813
Mailing Address - Country:US
Mailing Address - Phone:817-695-6666
Mailing Address - Fax:817-695-6632
Practice Address - Street 1:1601 W MARSHALL DR
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-2811
Practice Address - Country:US
Practice Address - Phone:972-946-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX102814225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T0662OtherBLUE CROSS BLUE SHIELD TX