Provider Demographics
NPI:1215037874
Name:FOGELSON, DAVID LESLIE (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LESLIE
Last Name:FOGELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2730 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 325
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-4743
Mailing Address - Country:US
Mailing Address - Phone:310-828-5015
Mailing Address - Fax:310-829-3877
Practice Address - Street 1:2730 WILSHIRE BLVD
Practice Address - Street 2:SUITE 325
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-4743
Practice Address - Country:US
Practice Address - Phone:310-828-5015
Practice Address - Fax:310-829-3877
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG391492084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA92050Medicare UPIN