Provider Demographics
NPI:1821051525
Name:FOGARTY, JACQUELINE MARY (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:MARY
Last Name:FOGARTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JACQUELINE
Other - Middle Name:MARY
Other - Last Name:FOGARTY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:JACQUELINE FOGARTY
Mailing Address - Street 1:409 OAK LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-1633
Mailing Address - Country:US
Mailing Address - Phone:434-572-8300
Mailing Address - Fax:434-572-1659
Practice Address - Street 1:409 OAK LN
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-1633
Practice Address - Country:US
Practice Address - Phone:434-572-8300
Practice Address - Fax:434-572-1659
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101035912207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6401767Medicaid
VA078069OtherANTHEM
VA200019809OtherRAILROAD MEDICARE
VA200019809OtherRAILROAD MEDICARE
VA078069OtherANTHEM