Healthcare Provider Details

I. General information

NPI: 1194799627
Provider Name (Legal Business Name): DIANA KATHLEEN FORT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VERDUGO HILLS MEDICAL ASSOCIATES 544 NORTH GLENDALE AVE.
GLENDALE CA
91206
US

IV. Provider business mailing address

2742 MAYFIELD AVE
LA CRESCENTA CA
91214-3816
US

V. Phone/Fax

Practice location:
  • Phone: 818-241-4331
  • Fax:
Mailing address:
  • Phone: 818-249-9134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA72238
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: