Healthcare Provider Details

I. General information

NPI: 1407827579
Provider Name (Legal Business Name): MICHAEL J FOGLI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 03/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1923 S UTICA AVE
TULSA OK
74104-6520
US

IV. Provider business mailing address

1923 S UTICA AVE
TULSA OK
74104-6520
US

V. Phone/Fax

Practice location:
  • Phone: 918-748-7650
  • Fax: 918-403-6341
Mailing address:
  • Phone: 918-748-7650
  • Fax: 918-403-6341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number24626
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number24626
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: