Provider Demographics
NPI:1043296445
Name:FOGARTY, BRENDA JOYCE (OD)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:JOYCE
Last Name:FOGARTY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:NH
Mailing Address - Zip Code:03079-3309
Mailing Address - Country:US
Mailing Address - Phone:603-893-5288
Mailing Address - Fax:603-893-4663
Practice Address - Street 1:167 S BROADWAY
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:NH
Practice Address - Zip Code:03079-3309
Practice Address - Country:US
Practice Address - Phone:603-893-5288
Practice Address - Fax:603-893-4663
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH472152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHRE2040Medicare ID - Type Unspecified