Provider Demographics
NPI:1316974207
Name:FOGARTY, CHERYL A (MD)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:A
Last Name:FOGARTY
Suffix:
Gender:F
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:PO BOX 3535
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-3535
Mailing Address - Country:US
Mailing Address - Phone:417-624-2621
Mailing Address - Fax:417-624-4652
Practice Address - Street 1:3103 MCCLELLAND BLVD
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1640
Practice Address - Country:US
Practice Address - Phone:417-624-2621
Practice Address - Fax:417-624-4652
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003008358207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200008560AMedicaid
MO208438408Medicaid
P00008391OtherRR MEDICARE
KS100454900BMedicaid
KS100454900AMedicaid
MO177853OtherANTHEM
OK200008560BMedicaid
OK200008560AMedicaid
MO990101292Medicare PIN