Provider Demographics
NPI:1982680062
Name:FOGARTY, THOMAS P (DO)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:P
Last Name:FOGARTY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:3768 BOARDMAN CANFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-8502
Mailing Address - Country:US
Mailing Address - Phone:330-533-8490
Mailing Address - Fax:330-533-8783
Practice Address - Street 1:3768 BOARDMAN CANFIELD RD
Practice Address - Street 2:
Practice Address - City:CANFIELD
Practice Address - State:OH
Practice Address - Zip Code:44406-8502
Practice Address - Country:US
Practice Address - Phone:330-533-8490
Practice Address - Fax:330-533-8783
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34003449207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0538958Medicaid
OH110131826OtherRR MEDICARE
OH110131826OtherRR MEDICARE
C02485Medicare UPIN