Healthcare Provider Details

I. General information

NPI: 1174557151
Provider Name (Legal Business Name): JOHN P FOGARTY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 CENTRE DR
MILTON VT
05468-3104
US

IV. Provider business mailing address

182 YACHT HAVEN DR
SHELBURNE VT
05482-7774
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-4322
  • Fax:
Mailing address:
  • Phone: 802-985-2755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: