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General NPI Number Information
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NPI Number | 1932271566
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Entity Type | Individual
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Provider Name | BRAD FORTUNE OD PHD
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Gender | Male
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Dates
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Enumeration Date | 11/15/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1040 NW 22ND AVENUE DEVERS EYE INSTITUTE
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City | PORTLAND
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State | OR
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Zip | 97210
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Country | US
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Telephone | 503-413-1198
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Fax | 503-413-5179
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Provider Business Mailing Address
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Address Line | 1225 NE SECOND AVENUE 3RD FLOOR DISCOVERIES IN SIGHT
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City | PORTLAND
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State | OR
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Zip | 97232
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Country | US
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Telephone | 503-413-1198
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Fax | 503-413-5179
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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 | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 2824T
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 9833
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License Number State | CA
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