Provider Demographics
NPI:1578593257
Name:FOGGETTI, MARY DANA (DO)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:DANA
Last Name:FOGGETTI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2414 KOHLER MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-3129
Mailing Address - Country:US
Mailing Address - Phone:920-457-4461
Mailing Address - Fax:920-459-1483
Practice Address - Street 1:2414 KOHLER MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-3129
Practice Address - Country:US
Practice Address - Phone:920-457-4461
Practice Address - Fax:920-459-1483
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112948207Q00000X
WI53914-21207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036112948Medicaid
WI100011708Medicaid
IL0222075OtherBLUE CROSS GROUP NUMBER
ILI45116Medicare UPIN
IL036112948Medicaid
IL920780Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER