Provider Demographics
NPI:1437130978
Name:FOGARTY, KEVIN GEORGE (DC)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:GEORGE
Last Name:FOGARTY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:839 BARTON BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3127
Mailing Address - Country:US
Mailing Address - Phone:321-636-5200
Mailing Address - Fax:321-639-0418
Practice Address - Street 1:839 BARTON BLVD
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3127
Practice Address - Country:US
Practice Address - Phone:321-636-5200
Practice Address - Fax:321-639-0418
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH5736111N00000X
CO3373111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL050371101Medicaid
FL22075AMedicare ID - Type Unspecified
FL050371101Medicaid