Provider Demographics
NPI:1629096243
Name:FOGLEMAN, CLARENCE E III (MD)
Entity Type:Individual
Prefix:
First Name:CLARENCE
Middle Name:E
Last Name:FOGLEMAN
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 E POLK ST
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-6267
Mailing Address - Country:US
Mailing Address - Phone:719-473-8801
Mailing Address - Fax:719-473-8581
Practice Address - Street 1:111 E POLK ST
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-6267
Practice Address - Country:US
Practice Address - Phone:719-473-8801
Practice Address - Fax:719-473-8581
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO27918207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1279181Medicaid
020006928OtherRR MEDICARE
COFO30141OtherBLUE SHIELD
COFO30141OtherBLUE SHIELD
020006928OtherRR MEDICARE