Healthcare Provider Details

I. General information

NPI: 1952307019
Provider Name (Legal Business Name): FORTUNEE MASSUDA DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 11/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1644 E 53RD ST
CHICAGO IL
60615-4210
US

IV. Provider business mailing address

9933 S WESTERN AVE STE 102
CHICAGO IL
60643-1810
US

V. Phone/Fax

Practice location:
  • Phone: 773-752-2111
  • Fax: 773-752-6703
Mailing address:
  • Phone: 773-445-8700
  • Fax: 773-445-4646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016003113
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number07000479A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code213EP0504X
TaxonomyPublic Medicine Podiatrist
License Number016003113
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code213EP0504X
TaxonomyPublic Medicine Podiatrist
License Number07000479A
License Number StateIN
# 5
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number016-003113
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number07000479A
License Number StateIN
# 7
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016003113
License Number StateIL
# 8
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number07000479A
License Number StateIN
# 9
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number016-003113
License Number StateIL
# 10
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number07000479A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: