Healthcare Provider Details

I. General information

NPI: 1568762995
Provider Name (Legal Business Name): KEVIN WILLIAM CLOGG O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2010
Last Update Date: 11/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 BUFFALO RD BLDG 700
ROCHESTER NY
14624-1367
US

IV. Provider business mailing address

2300 BUFFALO RD BLDG 700
ROCHESTER NY
14624-1367
US

V. Phone/Fax

Practice location:
  • Phone: 585-328-0153
  • Fax: 585-328-0158
Mailing address:
  • Phone: 585-328-0153
  • Fax: 585-328-0158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV007652-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: