Provider Demographics
NPI:1730172073
Name:FOGT, MICHAEL LEE (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LEE
Last Name:FOGT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 SE OCEAN BLVD
Mailing Address - Street 2:SUITE 106A
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-2471
Mailing Address - Country:US
Mailing Address - Phone:772-287-2663
Mailing Address - Fax:772-781-6797
Practice Address - Street 1:900 SE OCEAN BLVD
Practice Address - Street 2:SUITE 106A
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2471
Practice Address - Country:US
Practice Address - Phone:772-287-2663
Practice Address - Fax:772-781-6797
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC980152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4875080001OtherDMERC
FLT93822Medicare UPIN
FL19061AMedicare ID - Type Unspecified