Healthcare Provider Details

I. General information

NPI: 1962639757
Provider Name (Legal Business Name): MANUEL CORREA FORTES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2009
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 E ROLLINS ST STE 12000
ORLANDO FL
32804-5571
US

IV. Provider business mailing address

265 E ROLLINS ST STE 12000
ORLANDO FL
32804-5571
US

V. Phone/Fax

Practice location:
  • Phone: 407-975-0200
  • Fax:
Mailing address:
  • Phone: 407-975-0200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberME142665
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberDR.0067125
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberD0074808
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number0101265756
License Number StateVA
# 5
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberME142665
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: