Provider Demographics
NPI:1063858934
Name:FOGELSONG, TODD R (DO)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:R
Last Name:FOGELSONG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13121 OLIO RD
Practice Address - Street 2:SUITE 300
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-7237
Practice Address - Country:US
Practice Address - Phone:317-621-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-17
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02004531A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01723978OtherRR MEDICARE
IN201172960Medicaid
INP01723978OtherRR MEDICARE