Healthcare Provider Details

I. General information

NPI: 1285607986
Provider Name (Legal Business Name): RANDALL S FORTUNA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2006
Last Update Date: 10/31/2023
Certification Date: 10/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11234 ANDERSON ST # 7100
LOMA LINDA CA
92354-2804
US

IV. Provider business mailing address

11175 CAMPUS ST RM 21121
LOMA LINDA CA
92350-1700
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-4200
  • Fax: 909-558-2401
Mailing address:
  • Phone: 95-585-9599
  • Fax: 909-558-0348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number036109764
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number036-109764
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number036109764
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number49534
License Number StateAZ
# 5
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberA68643
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: