Healthcare Provider Details

I. General information

NPI: 1740277342
Provider Name (Legal Business Name): RICHARD A. FOGLE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 07/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 SW 160TH AVE SUITE 250
MIRAMAR FL
33027-6308
US

IV. Provider business mailing address

4605 MACCORKLE AVE SW
SOUTH CHARLESTON WV
25309-1311
US

V. Phone/Fax

Practice location:
  • Phone: 877-866-7123
  • Fax:
Mailing address:
  • Phone: 304-766-3600
  • Fax: 304-766-3477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number7670
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD7670
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: