Healthcare Provider Details

I. General information

NPI: 1851459309
Provider Name (Legal Business Name): JOSEPH GARY FORTUNATO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 03/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14027 5TH ST
DADE CITY FL
33525-4302
US

IV. Provider business mailing address

PO BOX 232
DADE CITY FL
33526-0232
US

V. Phone/Fax

Practice location:
  • Phone: 352-518-2000
  • Fax: 352-567-5193
Mailing address:
  • Phone: 352-518-2000
  • Fax: 352-567-5193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number18129
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: