Healthcare Provider Details

I. General information

NPI: 1548268733
Provider Name (Legal Business Name): DENISE FOG DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 01/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

748 KINGS HWY
WOODBURY NJ
08096-3157
US

IV. Provider business mailing address

1307 WHITE HORSE RD SUITE A-102
VOORHEES NJ
08043-2176
US

V. Phone/Fax

Practice location:
  • Phone: 856-848-4998
  • Fax: 856-848-9288
Mailing address:
  • Phone: 856-770-0504
  • Fax: 856-770-0395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMB077069
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: