Provider Demographics
NPI:1902826340
Name:FOGARTY, EDWARD F III (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:F
Last Name:FOGARTY
Suffix:III
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 1:17310 WRIGHT ST STE 103
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130-2405
Mailing Address - Country:US
Mailing Address - Phone:833-228-6889
Mailing Address - Fax:877-853-0376
Practice Address - Street 1:26 MAKOCHMNI
Practice Address - Street 2:
Practice Address - City:OGALLALA
Practice Address - State:NE
Practice Address - Zip Code:69153-5801
Practice Address - Country:US
Practice Address - Phone:701-595-1868
Practice Address - Fax:833-228-6889
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND94352085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND12455Medicaid
NDH87474Medicare UPIN
ND23309Medicare PIN