MEDICARE: DR. DARRELL LEE FORT M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	21698	KY

General Provider Information

NPI Number	:	1710998794
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DARRELL LEE FORT M.D.

Provider Business Mailing Address
First Line	:	1464 SE KANE ST
Second Line	:
City	:	ROSEBURG
State	:	OR
Zip	:	97470-4235
Country	:	US
Telephone Number	:	541-957-8570
Fax Number	:

Provider Business Practice Location Address
First Line	:	913 NW GARDEN VALLEY BLVD
Second Line	:
City	:	ROSEBURG
State	:	OR
Zip	:	97470-6523
Country	:	US
Telephone Number	:	541-440-1000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2006
Last Update Date	:	05/24/2026

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