Provider Demographics
NPI:1366455511
Name:FOGG-WABERSKI, JOANNA H (MD)
Entity Type:Individual
Prefix:DR
First Name:JOANNA
Middle Name:H
Last Name:FOGG-WABERSKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40,000 DEPT 634
Mailing Address - Street 2:HARTFORD HOSPITAL PROFESSIONAL SERVICES
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06151-0634
Mailing Address - Country:US
Mailing Address - Phone:860-545-7602
Mailing Address - Fax:860-545-7601
Practice Address - Street 1:200 RETREAT AVE
Practice Address - Street 2:INSTITUTE OF LIVING
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-3309
Practice Address - Country:US
Practice Address - Phone:860-545-7189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0284172084P0805X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001284173Medicaid
CT260002428Medicare ID - Type UnspecifiedFOR CLINIC C00814
CT001284173Medicaid