Healthcare Provider Details

I. General information

NPI: 1710998794
Provider Name (Legal Business Name): DARRELL LEE FORT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 NW GARDEN VALLEY BLVD
ROSEBURG OR
97470-6523
US

IV. Provider business mailing address

1464 SE KANE ST
ROSEBURG OR
97470-4235
US

V. Phone/Fax

Practice location:
  • Phone: 541-440-1000
  • Fax:
Mailing address:
  • Phone: 541-957-8570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number21698
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: