Provider Demographics
NPI:1306312731
Name:CUSTOM LONGEVITY P.A.
Entity type:Organization
Organization Name:CUSTOM LONGEVITY P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SVETLANA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-292-8074
Mailing Address - Street 1:4005 GULF SHORE BLVD N APT 402
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34103-3433
Mailing Address - Country:US
Mailing Address - Phone:917-292-8074
Mailing Address - Fax:
Practice Address - Street 1:4005 GULF SHORE BLVD N APT 402
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34103-3433
Practice Address - Country:US
Practice Address - Phone:917-292-8074
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty