Provider Demographics
NPI:1063995181
Name:FOGARTY, MCKENZIE SUZANNE (OD)
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:SUZANNE
Last Name:FOGARTY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34719 6TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-8714
Mailing Address - Country:US
Mailing Address - Phone:206-260-2503
Mailing Address - Fax:855-929-1515
Practice Address - Street 1:34719 6TH AVE S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-8714
Practice Address - Country:US
Practice Address - Phone:206-260-2503
Practice Address - Fax:855-929-1515
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-13
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60864286152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2139817Medicaid