Provider Demographics
NPI:1558477547
Name:BRENDA J. FOGARTY OD &ASSOC. P.A.
Entity Type:Organization
Organization Name:BRENDA J. FOGARTY OD &ASSOC. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:J
Authorized Official - Last Name:FOGARTY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:603-893-5288
Mailing Address - Street 1:167 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:NH
Mailing Address - Zip Code:03079-3309
Mailing Address - Country:US
Mailing Address - Phone:603-893-5288
Mailing Address - Fax:
Practice Address - Street 1:167 S BROADWAY
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:NH
Practice Address - Zip Code:03079-3309
Practice Address - Country:US
Practice Address - Phone:603-893-5288
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHNH 472152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH1043296445Medicare UPIN