Provider Demographics
NPI:1881694719
Name:KOGUT, KELLY ANN (MD, PC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:KOGUT
Suffix:
Gender:F
Credentials:MD, PC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:KOGUT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, PC
Mailing Address - Street 1:653 N TOWN CENTER DR
Mailing Address - Street 2:SUITE 507
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89144-0514
Mailing Address - Country:US
Mailing Address - Phone:702-233-8101
Mailing Address - Fax:702-242-0726
Practice Address - Street 1:653 N TOWN CENTER DR
Practice Address - Street 2:SUITE 507
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89144-0514
Practice Address - Country:US
Practice Address - Phone:702-233-8101
Practice Address - Fax:702-242-0726
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV93382086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002018507Medicaid