Healthcare Provider Details

I. General information

NPI: 1255349700
Provider Name (Legal Business Name): MICHAEL FORTGANG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 TAMARACK AVE PBM 118
DANBURY CT
06811-4822
US

IV. Provider business mailing address

230 SAUGATUCK AVE
WESTPORT CT
06880-6401
US

V. Phone/Fax

Practice location:
  • Phone: 203-739-7532
  • Fax: 203-743-2610
Mailing address:
  • Phone: 203-739-7532
  • Fax: 203-743-2610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number027366
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: