Healthcare Provider Details

I. General information

NPI: 1386044477
Provider Name (Legal Business Name): FORTUNA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2014
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11510 S FORTUNA RD SUITE A
YUMA AZ
85367-7843
US

IV. Provider business mailing address

11510 S FORTUNA RD STE A
YUMA AZ
85367-7843
US

V. Phone/Fax

Practice location:
  • Phone: 928-342-7046
  • Fax: 928-342-7018
Mailing address:
  • Phone: 928-342-7046
  • Fax: 928-342-7018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: OSWALD LOPEZ
Title or Position: MANAGER
Credential:
Phone: 928-342-7046