1891751624 NPI number — JOSEPH EDWIN FOGLE PH.D.

Table of content: JOSEPH EDWIN FOGLE PH.D. (NPI 1891751624)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891751624 NPI number — JOSEPH EDWIN FOGLE PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FOGLE
Provider First Name:
JOSEPH
Provider Middle Name:
EDWIN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FOGLE
Provider Other First Name:
JOE
Provider Other Middle Name:
E.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PH.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1891751624
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9412 WINDY KNOLL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75243-7560
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-348-2849
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7557 RAMBLER RD
Provider Second Line Business Practice Location Address:
SUITE 711
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75231-4142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-363-8391
Provider Business Practice Location Address Fax Number:
214-363-8316
Provider Enumeration Date:
04/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  24389 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00J05P . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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