Provider Demographics
NPI:1083033765
Name:FOGEL, ROBERTO (MD)
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:
Last Name:FOGEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5065 S STATE ROAD 7 STE 201
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33449-5439
Mailing Address - Country:US
Mailing Address - Phone:561-753-7487
Mailing Address - Fax:561-753-8161
Practice Address - Street 1:5065 S STATE ROAD 7 STE 201
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33449-5439
Practice Address - Country:US
Practice Address - Phone:561-753-7487
Practice Address - Fax:561-753-8161
Is Sole Proprietor?:No
Enumeration Date:2014-04-10
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMFC1715207R00000X
FLME134227207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14U55OtherBC/BS OF FL
FL011063400Medicaid