Provider Demographics
NPI:1366567844
Name:KOGAN, MICHELLE J
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:J
Last Name:KOGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8787 FRANCIS LEWIS BLVD
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11427-2867
Mailing Address - Country:US
Mailing Address - Phone:718-465-4999
Mailing Address - Fax:718-217-6101
Practice Address - Street 1:8787 FRANCIS LEWIS BLVD
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11427-2867
Practice Address - Country:US
Practice Address - Phone:718-465-4999
Practice Address - Fax:718-217-6101
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01799119Medicaid
NY01870Medicare ID - Type Unspecified