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General NPI Number Information
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NPI Number | 1376530816
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Entity Type | Individual
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Provider Name | FRAZIER T FORTENBERRY JR. MD
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Gender | Male
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Dates
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Enumeration Date | 09/30/2005
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Last Update Date | 07/21/2011
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Provider Practice Location Address
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Address Line | 630 PETER JEFFERSON PKWY SUITE 135
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City | CHARLOTTESVILLE
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State | VA
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Zip | 22911-8605
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Country | US
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Telephone | 434-244-5722
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Fax | 434-244-5723
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Provider Business Mailing Address
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Address Line | 630 PETER JEFFERSON PKWY SUITE 135
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City | CHARLOTTESVILLE
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State | VA
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Zip | 22911-8605
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Country | US
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Telephone | 434-244-5722
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Fax | 434-244-5723
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | 0101044989
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License Number State | VA
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