Provider Demographics
NPI:1396725214
Name:FOGARTY, KENNETH W II (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
Last Name:FOGARTY
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 908653
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-0926
Mailing Address - Country:US
Mailing Address - Phone:770-539-9600
Mailing Address - Fax:770-534-1470
Practice Address - Street 1:2350 LIMESTONE PKWY
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2013
Practice Address - Country:US
Practice Address - Phone:770-539-9600
Practice Address - Fax:770-534-1470
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA041118207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000679599CMedicaid
GA10053087OtherAMERIGROUP
GA0400123OtherUNITED HEALTHCARE
GA110225630OtherRR MEDICARE-GRP # CC4177
GA336330OtherWELLCARE
GA52542692OtherBCBS
GA8583747OtherCIGNA
GA336330OtherWELLCARE
GA52542692OtherBCBS