Provider Demographics
NPI:1447479829
Name:FORTUNA, GERALD RICHARD (MD)
Entity type:Individual
Prefix:DR
First Name:GERALD
Middle Name:RICHARD
Last Name:FORTUNA
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:PO BOX 6069
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171-6069
Mailing Address - Country:US
Mailing Address - Phone:803-936-7095
Mailing Address - Fax:803-936-7908
Practice Address - Street 1:2728 SUNSET BLVD STE 400
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4872
Practice Address - Country:US
Practice Address - Phone:803-936-7095
Practice Address - Fax:803-936-7908
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016023683208600000X, 2086S0102X, 2086S0129X
SC256392086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILENROLLEDMedicaid
MO1447479829Medicaid
OHFO4275232Medicare PIN
OH3035852Medicaid
OHFO4275231Medicare PIN