Healthcare Provider Details

I. General information

NPI: 1053313718
Provider Name (Legal Business Name): DIANE L FORTUNATO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 06/19/2021
Certification Date: 06/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2412 QUIRT LN
PUNTA GORDA FL
33983-2627
US

IV. Provider business mailing address

2412 QUIRT LN
PUNTA GORDA FL
33983-2627
US

V. Phone/Fax

Practice location:
  • Phone: 941-764-9480
  • Fax:
Mailing address:
  • Phone: 941-764-9480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA04648600
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number63562
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: