Provider Demographics
NPI:1386746113
Name:FOGARTY, ALFRED MATHEW JR (MD)
Entity type:Individual
Prefix:DR
First Name:ALFRED
Middle Name:MATHEW
Last Name:FOGARTY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ALFRED
Other - Middle Name:MATHEW
Other - Last Name:FOGARTY
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3109 ENGLISH TURN
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-2670
Mailing Address - Country:US
Mailing Address - Phone:318-548-0315
Mailing Address - Fax:318-251-9904
Practice Address - Street 1:823 W CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-4981
Practice Address - Country:US
Practice Address - Phone:318-251-9458
Practice Address - Fax:318-251-9904
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD0218292084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA022800OtherCDS
LAMD021829OtherMEDICAL LICENSE NUMBER
LA1661759Medicaid
LABF4150784OtherDEA
LA022800OtherCDS
LA5W215Medicare ID - Type Unspecified