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General NPI Number Information
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NPI Number | 1184710428
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Entity Type | Organization
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Legal Business Name | D L FORTSON M D P C
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Dates
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Enumeration Date | 10/05/2006
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Last Update Date | 12/03/2007
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Provider Practice Location Address
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Address Line | 1950 45TH AVE SUITE 100
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City | MUNSTER
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State | IN
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Zip | 46321-3917
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Country | US
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Telephone | 219-924-9277
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Fax | 219-924-9281
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Provider Business Mailing Address
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Address Line | 1950 45TH AVE SUITE 100
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City | MUNSTER
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State | IN
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Zip | 46321-3917
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Country | US
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Telephone | 219-924-9277
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Fax | 219-924-9281
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Authorized Official
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Title or Position | PRESIDENT & CEO
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Name | DARRYL L FORTSON
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Credential | M D
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Telephone | 219-924-9277
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 01037803
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License Number State | IN
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