1386746113 NPI number — DR. ALFRED MATHEW FOGARTY JR. M.D.

Table of content: MARTIN LIEBERMAN LCSW-R (NPI 1669028254)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386746113 NPI number — DR. ALFRED MATHEW FOGARTY JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FOGARTY
Provider First Name:
ALFRED
Provider Middle Name:
MATHEW
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FOGARTY
Provider Other First Name:
ALFRED
Provider Other Middle Name:
MATHEW
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
JR.
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1386746113
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3109 ENGLISH TURN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUSTON
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71270-2670
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-548-0315
Provider Business Mailing Address Fax Number:
318-251-9904

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
823 W CALIFORNIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RUSTON
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71270-4981
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-251-9458
Provider Business Practice Location Address Fax Number:
318-251-9904
Provider Enumeration Date:
09/02/2006

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: 2084P0800X , with the licence number:  MD021829 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 022800 . This is a "CDS" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: MD021829 . This is a "MEDICAL LICENSE NUMBER" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 1661759 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".