Provider Demographics
NPI:1326790668
Name:FOGARTY, MIKO
Entity Type:Individual
Prefix:
First Name:MIKO
Middle Name:
Last Name:FOGARTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134B ARDITH DR
Mailing Address - Street 2:
Mailing Address - City:ORINDA
Mailing Address - State:CA
Mailing Address - Zip Code:94563-4202
Mailing Address - Country:US
Mailing Address - Phone:925-255-3017
Mailing Address - Fax:
Practice Address - Street 1:134B ARDITH DR
Practice Address - Street 2:
Practice Address - City:ORINDA
Practice Address - State:CA
Practice Address - Zip Code:94563-4202
Practice Address - Country:US
Practice Address - Phone:925-255-3017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-18
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program