Healthcare Provider Details

I. General information

NPI: 1477998839
Provider Name (Legal Business Name): CLINT W KELLOGG D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2013
Last Update Date: 03/18/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 AMRON CT
COLUMBIA MO
65202
US

IV. Provider business mailing address

3600 AMRON CT
COLUMBIA MO
65202-1918
US

V. Phone/Fax

Practice location:
  • Phone: 573-874-1616
  • Fax: 573-875-0300
Mailing address:
  • Phone: 573-874-1616
  • Fax: 573-875-0300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberQ9396
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number2018010581
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: