Provider Demographics
NPI:1649253162
Name:FOGEL, LAWRENCE J (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:J
Last Name:FOGEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 CALIFORNIA BLVD
Mailing Address - Street 2:SUITE A-3
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2542
Mailing Address - Country:US
Mailing Address - Phone:805-543-1683
Mailing Address - Fax:805-543-3516
Practice Address - Street 1:628 CALIFORNIA BLVD
Practice Address - Street 2:SUITE A-3
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2542
Practice Address - Country:US
Practice Address - Phone:805-543-1683
Practice Address - Fax:805-543-3516
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG189772084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA120995100OtherUS DEPT OF LABOR
CA00G189770OtherBLUE SHIELD
CA00G189770Medicaid
CA130015179Medicare PIN
CA00G189770OtherBLUE SHIELD
CA120995100OtherUS DEPT OF LABOR