Healthcare Provider Details

I. General information

NPI: 1629451935
Provider Name (Legal Business Name): CORTNEY MARIE FOGARTY O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2015
Last Update Date: 04/30/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S CENTRAL AVE
EUREKA MO
63025-2002
US

IV. Provider business mailing address

101 S CENTRAL AVE
EUREKA MO
63025-2002
US

V. Phone/Fax

Practice location:
  • Phone: 636-938-9092
  • Fax: 636-938-3105
Mailing address:
  • Phone: 636-938-9092
  • Fax: 636-938-3105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2015021539
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: