Healthcare Provider Details

I. General information

NPI: 1528301785
Provider Name (Legal Business Name): BENJAMIN K KOGUTT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2013
Last Update Date: 10/30/2020
Certification Date: 10/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 PENNSYLVANIA AVE STE 600
FORT WORTH TX
76104-2133
US

IV. Provider business mailing address

1325 PENNSYLVANIA AVE STE 600
FORT WORTH TX
76104-2133
US

V. Phone/Fax

Practice location:
  • Phone: 682-267-8694
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License NumberQ3537
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: