Provider Demographics
NPI:1013364777
Name:FOG, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:FOG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 N PONTIAC TRL
Mailing Address - Street 2:
Mailing Address - City:WALLED LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390-3448
Mailing Address - Country:US
Mailing Address - Phone:248-669-2776
Mailing Address - Fax:
Practice Address - Street 1:620 N PONTIAC TRL
Practice Address - Street 2:
Practice Address - City:WALLED LAKE
Practice Address - State:MI
Practice Address - Zip Code:48390-3448
Practice Address - Country:US
Practice Address - Phone:248-669-2776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-23
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302041191390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program