Provider Demographics
NPI:1841409505
Name:MICHAEL FOGT P A
Entity Type:Organization
Organization Name:MICHAEL FOGT P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:FOGT
Authorized Official - Suffix:
Authorized Official - Credentials:O D
Authorized Official - Phone:772-287-2663
Mailing Address - Street 1:900 SE OCEAN BLVD
Mailing Address - Street 2:STE. 106A
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-2471
Mailing Address - Country:US
Mailing Address - Phone:772-287-2663
Mailing Address - Fax:772-781-6797
Practice Address - Street 1:900 SE OCEAN BLVD
Practice Address - Street 2:STE. 106A
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2471
Practice Address - Country:US
Practice Address - Phone:772-287-2663
Practice Address - Fax:772-781-6797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC980152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT93822Medicare UPIN
FL4875080001Medicare NSC
FLK4717Medicare PIN