Provider Demographics
NPI:1891715843
Name:FOGARTY, WILLIAM MARTIN JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:MARTIN
Last Name:FOGARTY
Suffix:JR
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 1:275 BLACKMER PL
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-3622
Mailing Address - Country:US
Mailing Address - Phone:314-961-2062
Mailing Address - Fax:
Practice Address - Street 1:275 BLACKMER PL
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-3622
Practice Address - Country:US
Practice Address - Phone:314-961-2062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002002022207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine