Provider Demographics
NPI:1427107283
Name:COGER, BRENTON RAVAL (MD)
Entity type:Individual
Prefix:DR
First Name:BRENTON
Middle Name:RAVAL
Last Name:COGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-829-4260
Mailing Address - Fax:
Practice Address - Street 1:1229 E SEMINOLE ST
Practice Address - Street 2:SUITE 220
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2227
Practice Address - Country:US
Practice Address - Phone:417-820-5150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009027848207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1427107283Medicaid
MO132680120Medicare PIN
MO132300123Medicare PIN