Provider Demographics
NPI:1184710428
Name:D L FORTSON M D P C
Entity type:Organization
Organization Name:D L FORTSON M D P C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:L
Authorized Official - Last Name:FORTSON
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:219-924-9277
Mailing Address - Street 1:1950 45TH AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-3917
Mailing Address - Country:US
Mailing Address - Phone:219-924-9277
Mailing Address - Fax:219-924-9281
Practice Address - Street 1:1950 45TH AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-3917
Practice Address - Country:US
Practice Address - Phone:219-924-9277
Practice Address - Fax:219-924-9281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037803207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000359839OtherANTHEM, BC/BS PROVIDER
IN000000359839OtherANTHEM, BC/BS PROVIDER
IN223280AMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER