Provider Demographics
NPI:1639170079
Name:FOGEL, JEFFREY MITCHELL (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:MITCHELL
Last Name:FOGEL
Suffix:
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 1:4308 HARBORWATCH LN
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-9704
Mailing Address - Country:US
Mailing Address - Phone:813-949-1435
Mailing Address - Fax:
Practice Address - Street 1:2705 DEKALB PIKE
Practice Address - Street 2:SUITE 205
Practice Address - City:NORRISTOWN
Practice Address - State:PA
Practice Address - Zip Code:19401-1852
Practice Address - Country:US
Practice Address - Phone:610-277-6400
Practice Address - Fax:610-275-8861
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD028946E208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
E67966Medicare UPIN