Provider Demographics
NPI:1104997212
Name:FOGAL, FRANK (PT)
Entity type:Individual
Prefix:
First Name:FRANK
Middle Name:
Last Name:FOGAL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2609 BEATRICE LN
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-9369
Mailing Address - Country:US
Mailing Address - Phone:209-551-3820
Mailing Address - Fax:
Practice Address - Street 1:1524 MCHENRY AVE STE 500
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4568
Practice Address - Country:US
Practice Address - Phone:209-575-5801
Practice Address - Fax:209-575-0115
Is Sole Proprietor?:No
Enumeration Date:2006-11-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21525225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist