=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285607986
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RANDALL S FORTUNA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2006
-----------------------------------------------------
Last Update Date | 10/31/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11234 ANDERSON ST # 7100
-----------------------------------------------------
City | LOMA LINDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92354-2804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-558-4200
-----------------------------------------------------
Fax | 909-558-2401
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11175 CAMPUS ST RM 21121
-----------------------------------------------------
City | LOMA LINDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92350-1700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 95-585-9599
-----------------------------------------------------
Fax | 909-558-0348
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0129X
-----------------------------------------------------
Taxonomy Name | Vascular Surgery Physician
-----------------------------------------------------
License Number | 036109764
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2086S0129X
-----------------------------------------------------
Taxonomy Name | Vascular Surgery Physician
-----------------------------------------------------
License Number | 036-109764
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208G00000X
-----------------------------------------------------
Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
-----------------------------------------------------
License Number | 036109764
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 208G00000X
-----------------------------------------------------
Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
-----------------------------------------------------
License Number | 49534
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 208G00000X
-----------------------------------------------------
Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
-----------------------------------------------------
License Number | A68643
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------