Basic Information
| Provider Information | |||||||||
| NPI: | 1205195112 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COGBURN | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | KENNETH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 SUTTER ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941044009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4156586791 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4 EMBARCADERO CTR LBBY LEVEL | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941114130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4155294566 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2012 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 127767 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 018651200 | 05 | FL | MEDICAID |