Provider Demographics
NPI:1699761684
Name:FOGG, ANDREW W (DC)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:W
Last Name:FOGG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1775 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-1338
Mailing Address - Country:US
Mailing Address - Phone:707-445-8080
Mailing Address - Fax:707-445-8088
Practice Address - Street 1:1775 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-1338
Practice Address - Country:US
Practice Address - Phone:707-445-8080
Practice Address - Fax:707-445-8088
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-23
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 26719111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0267190OtherMEDICARE PTAN
CADC0267190Medicaid
CADC0267190OtherMEDICARE PTAN