Provider Demographics
NPI:1275834608
Name:FOGLE, DEREK LEE (DPT)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:LEE
Last Name:FOGLE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9099 RIDGEFIELD DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-6713
Mailing Address - Country:US
Mailing Address - Phone:301-696-5595
Mailing Address - Fax:301-696-0846
Practice Address - Street 1:9099 RIDGEFIELD DR
Practice Address - Street 2:SUITE 202
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-6713
Practice Address - Country:US
Practice Address - Phone:301-696-5595
Practice Address - Fax:301-696-0846
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-17
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23481225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist