MEDICARE: MS. MARTINA S FOGT MPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT30287	CA
2	225100000X	Physical Therapist	30287	CA

General Provider Information

NPI Number	:	1134105133
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARTINA S FOGT MPT

Provider Business Mailing Address
First Line	:	11901 SANTA MONICA BLVD STE 201
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-2767
Country	:	US
Telephone Number	:	310-982-2472
Fax Number	:	310-479-2329

Provider Business Practice Location Address
First Line	:	11901 SANTA MONICA BLVD STE 201
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-2767
Country	:	US
Telephone Number	:	310-982-2472
Fax Number	:	310-479-2329

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/21/2005
Last Update Date	:	02/21/2019

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