Provider Demographics
NPI:1316720253
Name:FOG, STEPHEN CHASE (LAC)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:CHASE
Last Name:FOG
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 OAKRIDGE CMNS
Mailing Address - Street 2:
Mailing Address - City:SOUTH SALEM
Mailing Address - State:NY
Mailing Address - Zip Code:10590-2438
Mailing Address - Country:US
Mailing Address - Phone:203-536-1081
Mailing Address - Fax:203-966-6002
Practice Address - Street 1:402 OAKRIDGE CMNS
Practice Address - Street 2:
Practice Address - City:SOUTH SALEM
Practice Address - State:NY
Practice Address - Zip Code:10590-2438
Practice Address - Country:US
Practice Address - Phone:203-536-1081
Practice Address - Fax:203-966-6002
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007145171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist