Basic Information
Provider Information | |||||||||
NPI: | 1851719421 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KOOGLER | ||||||||
FirstName: | ANDREW | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 410 W 10TH AVE | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432101240 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6142938484 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 11306 BRIDGEPORT WAY SW STE D | ||||||||
Address2: |   | ||||||||
City: | LAKEWOOD | ||||||||
State: | WA | ||||||||
PostalCode: | 984993037 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2539839390 | ||||||||
FaxNumber: | 3607338320 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/01/2014 | ||||||||
LastUpdateDate: | 10/02/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 60886566 | WA | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
ID | Type | State | Issuer | Description | MD60886566 | 01 | WA | WA LICENSE | OTHER |