Provider Demographics
NPI:1730412412
Name:KOGAN, VICTORIA (MD)
Entity type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:
Last Name:KOGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5409 AVENUE O
Mailing Address - Street 2:PO BOX 1470
Mailing Address - City:FORT MADISON
Mailing Address - State:IA
Mailing Address - Zip Code:52627-9601
Mailing Address - Country:US
Mailing Address - Phone:319-376-2134
Mailing Address - Fax:319-376-2188
Practice Address - Street 1:5409 AVENUE O
Practice Address - Street 2:
Practice Address - City:FORT MADISON
Practice Address - State:IA
Practice Address - Zip Code:52627-9601
Practice Address - Country:US
Practice Address - Phone:319-376-2134
Practice Address - Fax:319-376-2188
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-11
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY254723207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1730412412Medicaid
IA511790005OtherWELLMARK/ BLUE CROSS/ BLUE SHIELD
IA511790005OtherWELLMARK/ BLUE CROSS/ BLUE SHIELD