Provider Demographics
NPI:1255937652
Name:FOGG, DEBORAH L
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:L
Last Name:FOGG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5784 DORIS DR
Mailing Address - Street 2:
Mailing Address - City:BROOKPARK
Mailing Address - State:OH
Mailing Address - Zip Code:44142-2108
Mailing Address - Country:US
Mailing Address - Phone:216-990-9572
Mailing Address - Fax:
Practice Address - Street 1:5784 DORIS DR
Practice Address - Street 2:
Practice Address - City:BROOKPARK
Practice Address - State:OH
Practice Address - Zip Code:44142-2108
Practice Address - Country:US
Practice Address - Phone:216-990-9572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH253Z00000X
253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1805489Medicaid