Healthcare Provider Details

I. General information

NPI: 1740390053
Provider Name (Legal Business Name): KEITH FORTIER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 01/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

594 COPENHAGEN RD
WATERFORD VT
05819-9055
US

IV. Provider business mailing address

594 COPENHAGEN RD
WATERFORD VT
05819-9055
US

V. Phone/Fax

Practice location:
  • Phone: 802-748-8573
  • Fax: 707-734-8573
Mailing address:
  • Phone: 802-748-8573
  • Fax: 707-734-8573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number042-0006155
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: