Basic Information
| Provider Information | |||||||||
| NPI: | 1083657084 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLOGG | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 814 PIERCE ST | ||||||||
| Address2: | STE102 | ||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511011061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122262600 | ||||||||
| FaxNumber: | 7122262605 | ||||||||
| Practice Location | |||||||||
| Address1: | 4545 SERGEANT RD | ||||||||
| Address2: | |||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511064706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122742400 | ||||||||
| FaxNumber: | 7122741484 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 01/31/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 02201 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1098830 | 05 | IA | MEDICAID | 7764992 | 05 | SD | MEDICAID | 70220 | 01 | IA | WELLMARK OF IA | OTHER |