Healthcare Provider Details

I. General information

NPI: 1467804229
Provider Name (Legal Business Name): ETHAN KELLOGG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2016
Last Update Date: 08/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 1ST AVE
NEW YORK NY
10029-7494
US

IV. Provider business mailing address

1677 LEXINGTON AVE APT 4E
NEW YORK NY
10029-4666
US

V. Phone/Fax

Practice location:
  • Phone: 212-423-6262
  • Fax:
Mailing address:
  • Phone: 585-905-1974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number299407
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: