Healthcare Provider Details

I. General information

NPI: 1962085035
Provider Name (Legal Business Name): RYAN FOGG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2021
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 BARNHILL DR
INDIANAPOLIS IN
46202-5116
US

IV. Provider business mailing address

535 BARNHILL DR
INDIANAPOLIS IN
46202-5116
US

V. Phone/Fax

Practice location:
  • Phone: 317-278-0221
  • Fax:
Mailing address:
  • Phone: 317-278-0221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number01099672A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: