Provider Demographics
NPI:1679532840
Name:FOGWELL, TED E (MD)
Entity type:Individual
Prefix:DR
First Name:TED
Middle Name:E
Last Name:FOGWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8160 WALNUT HILL LN
Mailing Address - Street 2:SUITE 220
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4339
Mailing Address - Country:US
Mailing Address - Phone:214-750-0980
Mailing Address - Fax:
Practice Address - Street 1:8160 WALNUT HILL LN
Practice Address - Street 2:SUITE 220
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4339
Practice Address - Country:US
Practice Address - Phone:214-750-0980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE0917207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX86X001OtherBCBS PROVIDER NUMBER
TX169343401Medicaid
TX86X001OtherBCBS PROVIDER NUMBER
TX00R01ZMedicare ID - Type Unspecified
TX169343401Medicaid