Provider Demographics
NPI:1760527469
Name:FOGARTY, THOMAS MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:MICHAEL
Last Name:FOGARTY
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 1:10369 DEMOCRACY LN
Mailing Address - Street 2:#A
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2548
Mailing Address - Country:US
Mailing Address - Phone:703-383-6933
Mailing Address - Fax:703-383-6936
Practice Address - Street 1:10369 DEMOCRACY LN
Practice Address - Street 2:#A
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2548
Practice Address - Country:US
Practice Address - Phone:703-383-6933
Practice Address - Fax:703-383-6936
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010425132084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD76193Medicare UPIN
VA569091Medicare ID - Type Unspecified