Provider Demographics
NPI:1427041342
Name:FOGT, JEFFREY CLAY (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:CLAY
Last Name:FOGT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 CLINTON ST
Mailing Address - Street 2:STE 1000
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-2176
Mailing Address - Country:US
Mailing Address - Phone:419-782-4831
Mailing Address - Fax:419-784-0197
Practice Address - Street 1:101 CLINTON ST
Practice Address - Street 2:STE 1000
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-2176
Practice Address - Country:US
Practice Address - Phone:419-782-4831
Practice Address - Fax:419-784-0197
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4103152W00000X
OHT1490152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0357310001OtherDMEPOS
F00655493Medicare ID - Type Unspecified
T92701Medicare UPIN