Provider Demographics
NPI:1861532350
Name:KELLOGG, JEFFREY D (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:D
Last Name:KELLOGG
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:PO BOX 1880
Mailing Address - Street 2:
Mailing Address - City:SHEPHERDSTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:25443-1880
Mailing Address - Country:US
Mailing Address - Phone:304-876-9321
Mailing Address - Fax:304-876-1481
Practice Address - Street 1:45 MADDEX DR
Practice Address - Street 2:
Practice Address - City:SHEPHERDSTOWN
Practice Address - State:WV
Practice Address - Zip Code:25443-4322
Practice Address - Country:US
Practice Address - Phone:304-876-9321
Practice Address - Fax:304-876-1481
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV15594207QA0000X, 207QA0505X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV8805061Medicare PIN
WVC35222Medicare UPIN