Provider Demographics
NPI:1831338151
Name:FOGG, JASON K (DO)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:K
Last Name:FOGG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42420-2783
Mailing Address - Country:US
Mailing Address - Phone:709-578-8002
Mailing Address - Fax:270-957-8797
Practice Address - Street 1:1305 N ELM ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-2783
Practice Address - Country:US
Practice Address - Phone:270-957-8800
Practice Address - Fax:270-957-8797
Is Sole Proprietor?:No
Enumeration Date:2009-02-10
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT012163208100000X
KY035042081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100205830Medicaid
KYK049750Medicare PIN