Provider Demographics
NPI:1083314819
Name:FOGEL, TRAVIS SCOTT (OD)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:SCOTT
Last Name:FOGEL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 HOLLYWOOD DR STE 102
Mailing Address - Street 2:
Mailing Address - City:BUTLER
Mailing Address - State:PA
Mailing Address - Zip Code:16001-7604
Mailing Address - Country:US
Mailing Address - Phone:724-283-3500
Mailing Address - Fax:
Practice Address - Street 1:120 HOLLYWOOD DR STE 102
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:PA
Practice Address - Zip Code:16001-7604
Practice Address - Country:US
Practice Address - Phone:724-283-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003983152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist