Provider Demographics
NPI:1295782894
Name:FOGT, DARWIN LANCE (MPT)
Entity type:Individual
Prefix:
First Name:DARWIN
Middle Name:LANCE
Last Name:FOGT
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 CULVER BLVD
Mailing Address - Street 2:
Mailing Address - City:PLAYA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90293-7784
Mailing Address - Country:US
Mailing Address - Phone:310-915-6100
Mailing Address - Fax:310-915-0100
Practice Address - Street 1:11825 MAJOR ST
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-6356
Practice Address - Country:US
Practice Address - Phone:310-915-6100
Practice Address - Fax:310-915-0100
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT26595225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT26595Medicare ID - Type Unspecified