Provider Demographics
NPI:1194708081
Name:FOGELSON, NICHOLAS S (MD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:S
Last Name:FOGELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 SW 10TH AVE STE 907
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2710
Mailing Address - Country:US
Mailing Address - Phone:503-715-1377
Mailing Address - Fax:503-715-2717
Practice Address - Street 1:511 SW 10TH AVE STE 907
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2710
Practice Address - Country:US
Practice Address - Phone:503-715-1377
Practice Address - Fax:503-715-2717
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23610207V00000X
HI13367207V00000X
OR173545207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA35093922Medicare PIN
HI569725Medicaid
23610OtherSC MEDICAL LICENSE
I37643Medicare UPIN
SC236160Medicaid
HI8992228OtherUNIVERSITY HEALTH ALLIANC