MEDICARE: THERESA FORTALEZA-DAWSON MD PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0300X	Geriatric Medicine (Internal Medicine) Physician	ME81298	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	50293	OTHER	FL	NEIGHBORHOOD HEALTH
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	280599	OTHER	FL	AVMED
4	03018	OTHER	FL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1144426040
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THERESA FORTALEZA-DAWSON MD PA

Provider Business Mailing Address
First Line	:	6278 N FEDERAL HWY
Second Line	:	SUITE 183
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33308-1916
Country	:	US
Telephone Number	:	954-938-8998
Fax Number	:	954-938-8984

Provider Business Practice Location Address
First Line	:	2006 NE 49TH ST
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33308-4524
Country	:	US
Telephone Number	:	954-938-8998
Fax Number	:	954-938-8984

Authorized Official
Title or Position	:	OWNER
Name	:	DR. THERESA FORTALEZA-DAWSON
Credential	:	M.D.
Telephone Number	:	954-938-8998

Provider Enumeration Date	:	06/26/2007
Last Update Date	:	01/24/2013

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