Provider Demographics
NPI:1417167271
Name:FOGO, JUSTIN WADE (DC)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:WADE
Last Name:FOGO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:398 CHESSER ROAD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CHELSEA
Mailing Address - State:AL
Mailing Address - Zip Code:35043
Mailing Address - Country:US
Mailing Address - Phone:205-678-1000
Mailing Address - Fax:205-678-1001
Practice Address - Street 1:398 CHESSER ROAD
Practice Address - Street 2:SUITE 2
Practice Address - City:CHELSEA
Practice Address - State:AL
Practice Address - Zip Code:35043
Practice Address - Country:US
Practice Address - Phone:205-678-1000
Practice Address - Fax:205-678-1001
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2069111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51525708OtherBCBS PROVIDER
ALU97351Medicare UPIN
AL025708FOGMedicare UPIN
ALJWFOGOMedicare UPIN