Provider Demographics
NPI:1295954758
Name:TED E. FOGWELL, M.D., P.A.
Entity type:Organization
Organization Name:TED E. FOGWELL, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TED
Authorized Official - Middle Name:E
Authorized Official - Last Name:FOGWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-750-0980
Mailing Address - Street 1:8160 WALNUT HILL LN
Mailing Address - Street 2:SUITE 220
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4339
Mailing Address - Country:US
Mailing Address - Phone:214-750-0980
Mailing Address - Fax:214-361-1927
Practice Address - Street 1:8160 WALNUT HILL LN
Practice Address - Street 2:SUITE 220
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4339
Practice Address - Country:US
Practice Address - Phone:214-750-0980
Practice Address - Fax:214-361-1927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE0917207VH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VH0002XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyHospice and Palliative MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00R01ZMedicare ID - Type Unspecified
TXB22743Medicare UPIN