Healthcare Provider Details

I. General information

NPI: 1538255823
Provider Name (Legal Business Name): DARRYL L FORTSON M D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 01/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2704 N TENAYA WAY
LAS VEGAS NV
89128-0424
US

IV. Provider business mailing address

PO BOX 15645
LAS VEGAS NV
89114-5645
US

V. Phone/Fax

Practice location:
  • Phone: 702-243-8500
  • Fax: 702-363-8195
Mailing address:
  • Phone: 702-243-8500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01037803
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01037803A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number15697
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: