Healthcare Provider Details

I. General information

NPI: 1578601258
Provider Name (Legal Business Name): JORGE FORTUNO MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 DUKE ST UNIVERSITY GARDENS
SAN JUAN PR
00927
US

IV. Provider business mailing address

913 DUKE ST UNIVERSITY GARDENS
SAN JUAN PR
00927
US

V. Phone/Fax

Practice location:
  • Phone: 787-765-4809
  • Fax: 787-765-6176
Mailing address:
  • Phone: 787-765-4809
  • Fax: 787-765-6176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number588
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: