SHANE C FOGO MD Medical Doctor License verification

Business Entity

CANCELLED

License Type

Medical Doctor

Description

TEMPORARY MEDICAL PERMIT

License Number

125044915

License Status

CANCELLED

Business

Title

First Name

SHANE

Middle

Last Name

FOGO

Business Name

SHANE C FOGO MD

Original Issue Date

07/01/2002

Effective Date

07/01/2002

Expiration Date

06/30/2005

City

PEORIA

State

Zip

61602

County

PEORIA

Specialty/Qualifier

Family Medicine

Ever Disciplined

LastModifiedDate

09/22/2006