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General NPI Number Information
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NPI Number | 1821051525
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Entity Type | Individual
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Provider Name | JACQUELINE MARY FOGARTY M.D.
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Gender | Female
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Dates
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Enumeration Date | 04/11/2006
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Last Update Date | 11/18/2010
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Provider Practice Location Address
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Address Line | 409 OAK LN
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City | SOUTH BOSTON
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State | VA
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Zip | 24592-1633
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Country | US
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Telephone | 434-572-8300
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Fax | 434-572-1659
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Provider Business Mailing Address
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Address Line | 409 OAK LN
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City | SOUTH BOSTON
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State | VA
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Zip | 24592-1633
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Country | US
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Telephone | 434-572-8300
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Fax | 434-572-1659
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 0101035912
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License Number State | VA
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