Provider Demographics
NPI:1447283627
Name:FOG, DANIEL (DPT)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:FOG
Suffix:
Gender:
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3998 WESTDALE PKWY SW STE 300
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52404-9201
Mailing Address - Country:US
Mailing Address - Phone:319-396-0222
Mailing Address - Fax:319-395-6015
Practice Address - Street 1:2166 BLAIRS FERRY RD
Practice Address - Street 2:
Practice Address - City:HIAWATHA
Practice Address - State:IA
Practice Address - Zip Code:52233-7902
Practice Address - Country:US
Practice Address - Phone:319-395-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA074065225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIB1212Medicare PIN
IAIB1212039Medicare PIN