Healthcare Provider Details

I. General information

NPI: 1649249616
Provider Name (Legal Business Name): KENNETH K. WOGENSEN, MD. INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 03/07/2023
Certification Date: 01/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 NORTH FIRST AVENUE SUITE A
ARCADIA CA
91006-2534
US

IV. Provider business mailing address

1015 NORTH FIRST AVENUE SUITE A
ARCADIA CA
91006-2534
US

V. Phone/Fax

Practice location:
  • Phone: 626-566-2866
  • Fax: 626-566-2850
Mailing address:
  • Phone: 626-566-2866
  • Fax: 626-566-2850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberG52870
License Number StateCA

VIII. Authorized Official

Name: DR. KENNETH K WOGENSEN
Title or Position: PRESIDENT
Credential: MD
Phone: 626-566-2866