Provider Demographics
NPI:1891778825
Name:FOGARTY, ROBERT S (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:S
Last Name:FOGARTY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12484 LAKE UNDERHILL RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-7100
Mailing Address - Country:US
Mailing Address - Phone:407-281-0707
Mailing Address - Fax:407-273-4793
Practice Address - Street 1:12484 LAKE UNDERHILL RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-7100
Practice Address - Country:US
Practice Address - Phone:407-281-0707
Practice Address - Fax:407-273-4793
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-23
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0006917111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL050371100Medicaid
FL55549Medicare PIN