Provider Demographics
NPI:1649432766
Name:FORTUNE, REGINE (DO)
Entity type:Individual
Prefix:MS
First Name:REGINE
Middle Name:
Last Name:FORTUNE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 FRANKLIN AVE
Mailing Address - Street 2:LONG ISLAND JEWISH VALLEY STREAM
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580
Mailing Address - Country:US
Mailing Address - Phone:516-256-6000
Mailing Address - Fax:
Practice Address - Street 1:900 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-2145
Practice Address - Country:US
Practice Address - Phone:914-681-2560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251171207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine