Provider Demographics
NPI:1962599530
Name:KOGER, O'NEAL WILSON JR (MD)
Entity type:Individual
Prefix:DR
First Name:O'NEAL
Middle Name:WILSON
Last Name:KOGER
Suffix:JR
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 1:30301 WOODWARD AVE
Mailing Address - Street 2:120
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48302
Mailing Address - Country:US
Mailing Address - Phone:248-435-6622
Mailing Address - Fax:248-435-7453
Practice Address - Street 1:30301 WOODWARD AVE
Practice Address - Street 2:120
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48302
Practice Address - Country:US
Practice Address - Phone:248-435-6622
Practice Address - Fax:248-435-7453
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301053536207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP67011OtherOLD BCN
MI0706328251OtherINDIV B
MI3361759Medicaid
MI070012496OtherRAILROAD MEDICARE
MI632825OtherNEW BCN
MI9679933OtherCIGNA
MIS38359OtherHAP
MI4113337OtherAETNA
MI070F37332OtherBCBS
MI070012496OtherRAILROAD MEDICARE
MIOM36310Medicare ID - Type Unspecified