Healthcare Provider Details

I. General information

NPI: 1689700494
Provider Name (Legal Business Name): KIM EDWARD KOGER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 02/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 JUPITER LAKES BLVD BLDG 5000 SUITE 202
JUPITER FL
33458-7191
US

IV. Provider business mailing address

4600 MILITARY TRAIL SUITE 202
JUPITER FL
33458
US

V. Phone/Fax

Practice location:
  • Phone: 561-748-1565
  • Fax: 561-748-1568
Mailing address:
  • Phone: 561-748-1565
  • Fax: 561-748-1568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number75895
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberME75895
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: