Provider Demographics
NPI:1801897764
Name:FOGELBERG, KENNETH W (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:W
Last Name:FOGELBERG
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 1:910 NAN CT
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-3151
Mailing Address - Country:US
Mailing Address - Phone:805-614-4023
Mailing Address - Fax:
Practice Address - Street 1:910 NAN CT
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-3151
Practice Address - Country:US
Practice Address - Phone:805-614-4023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00035700207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAA43551Medicare UPIN