Healthcare Provider Details

I. General information

NPI: 1710985817
Provider Name (Legal Business Name): MARIO D. FORTE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 11/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 DELAWARE ST
LONGVIEW WA
98632-2310
US

IV. Provider business mailing address

PO BOX 3002
LONGVIEW WA
98632-0302
US

V. Phone/Fax

Practice location:
  • Phone: 360-501-3500
  • Fax: 360-501-3555
Mailing address:
  • Phone: 360-414-2048
  • Fax: 360-575-6749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD00027430
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: