Provider Demographics
NPI:1871551952
Name:FOGG, C DOUGLAS (MD)
Entity type:Individual
Prefix:
First Name:C
Middle Name:DOUGLAS
Last Name:FOGG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 HIDDEN BAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH DARTMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02748
Mailing Address - Country:US
Mailing Address - Phone:508-993-1317
Mailing Address - Fax:
Practice Address - Street 1:4499 ACUSHNET AVE
Practice Address - Street 2:NEW BEDFORD REHABILITATION HOSPITAL
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02745
Practice Address - Country:US
Practice Address - Phone:508-985-9082
Practice Address - Fax:508-995-0742
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA33680208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0162361Medicaid
MA0162361Medicaid
K11226Medicare ID - Type Unspecified