Provider Demographics
NPI:1134105133
Name:FOGT, MARTINA S (MPT)
Entity Type:Individual
Prefix:MS
First Name:MARTINA
Middle Name:S
Last Name:FOGT
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:MARTINA
Other - Middle Name:S
Other - Last Name:MARCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:11901 SANTA MONICA BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-2767
Mailing Address - Country:US
Mailing Address - Phone:310-982-2472
Mailing Address - Fax:310-479-2329
Practice Address - Street 1:11901 SANTA MONICA BLVD STE 201
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-2767
Practice Address - Country:US
Practice Address - Phone:310-982-2472
Practice Address - Fax:310-479-2329
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT30287225100000X
CA30287225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT30287AMedicare ID - Type UnspecifiedPPIN