Provider Demographics
NPI:1548268733
Name:FOG, DENISE (DO)
Entity type:Individual
Prefix:DR
First Name:DENISE
Middle Name:
Last Name:FOG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1307 WHITE HORSE RD
Mailing Address - Street 2:SUITE A-102
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-2176
Mailing Address - Country:US
Mailing Address - Phone:856-770-0504
Mailing Address - Fax:856-770-0395
Practice Address - Street 1:748 KINGS HWY
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-3157
Practice Address - Country:US
Practice Address - Phone:856-848-4998
Practice Address - Fax:856-848-9288
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB0770692085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0015385Medicaid
NJ0015385Medicaid
NJ078682AFMMedicare ID - Type Unspecified