Healthcare Provider Details

I. General information

NPI: 1003324682
Provider Name (Legal Business Name): MR. DAVID E FORTIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2018
Last Update Date: 01/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10441 MIDLOTHIAN TURNPIKE
RICHMOND VA
23235
US

IV. Provider business mailing address

10441 MIDLOTHIAN TPKE
NORTH CHESTERFIELD VA
23235-4407
US

V. Phone/Fax

Practice location:
  • Phone: 804-320-6915
  • Fax: 804-320-6917
Mailing address:
  • Phone: 804-320-6915
  • Fax: 804-320-6917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number2101002201
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: