Provider Demographics
NPI:1083103865
Name:FOGT, DANIEL ROSS
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:ROSS
Last Name:FOGT
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 1:630 W MAIN ST STE 304
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-2171
Mailing Address - Country:US
Mailing Address - Phone:937-283-2520
Mailing Address - Fax:
Practice Address - Street 1:630 W MAIN ST STE 304
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-2171
Practice Address - Country:US
Practice Address - Phone:937-283-2520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-07
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.148707208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery