Provider Demographics
NPI:1649249616
Name:KENNETH K. WOGENSEN, MD. INC
Entity type:Organization
Organization Name:KENNETH K. WOGENSEN, MD. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:K
Authorized Official - Last Name:WOGENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-566-2866
Mailing Address - Street 1:1015 NORTH 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 NORTH 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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG528702084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG52870OtherSTATE LICENSE
CAG52870OtherSTATE LICENSE
CAA52373Medicare UPIN
CAWG52870AMedicare ID - Type UnspecifiedMEDICARE