Provider Demographics
NPI:1427258169
Name:FOGG, TREVOR KEITH (OD)
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:KEITH
Last Name:FOGG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:757 PACIFIC ST
Mailing Address - Street 2:SUITE C-1
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-2819
Mailing Address - Country:US
Mailing Address - Phone:831-372-8181
Mailing Address - Fax:831-372-7433
Practice Address - Street 1:757 PACIFIC ST
Practice Address - Street 2:SUITE C-1
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-2819
Practice Address - Country:US
Practice Address - Phone:831-372-8181
Practice Address - Fax:831-372-7433
Is Sole Proprietor?:No
Enumeration Date:2007-07-20
Last Update Date:2011-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13318T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEL281ZMedicare PIN