Provider Demographics
NPI:1114488392
Name:FOGEL, BENJAMIN F (DPT, CERT MDT)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:F
Last Name:FOGEL
Suffix:
Gender:M
Credentials:DPT, CERT MDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 AVENUE A APT 1245
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78215-1274
Mailing Address - Country:US
Mailing Address - Phone:330-224-6818
Mailing Address - Fax:
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-916-7812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-28
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2000X
FLPT31722261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy