Provider Demographics
NPI:1275834608
Name:FOGLE, DEREK LEE (DPT)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:LEE
Last Name:FOGLE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 THOMAS JOHNSON DR STE E
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4742
Mailing Address - Country:US
Mailing Address - Phone:301-694-8311
Mailing Address - Fax:301-695-4324
Practice Address - Street 1:165 THOMAS JOHNSON DR STE E
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4742
Practice Address - Country:US
Practice Address - Phone:301-694-8311
Practice Address - Fax:301-695-4324
Is Sole Proprietor?:No
Enumeration Date:2010-11-17
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23481225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist