Provider Demographics
NPI:1093246902
Name:FOGARTY, WILLIAM MARTIN IV (DO)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:MARTIN
Last Name:FOGARTY
Suffix:IV
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:3898 PARKMEAD DR APT 309
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-4033
Mailing Address - Country:US
Mailing Address - Phone:314-570-8856
Mailing Address - Fax:
Practice Address - Street 1:700 CHILDRENS DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2639
Practice Address - Country:US
Practice Address - Phone:614-722-2530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-22
Last Update Date:2020-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.0143382080P0202X
FLUO5440390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology