Provider Demographics
NPI:1245227024
Name:FOGLE, DIERDRE A (OD)
Entity Type:Individual
Prefix:DR
First Name:DIERDRE
Middle Name:A
Last Name:FOGLE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8089 S LINCOLN ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80122-2700
Mailing Address - Country:US
Mailing Address - Phone:303-471-2015
Mailing Address - Fax:303-471-2042
Practice Address - Street 1:8089 S LINCOLN ST STE 103
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80122-2719
Practice Address - Country:US
Practice Address - Phone:303-471-2015
Practice Address - Fax:303-471-2042
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1961152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COU73952Medicare UPIN
COCO40502Medicare PIN