Provider Demographics
NPI:1003163320
Name:DR. DONALD J FORNACE DO FACC INC
Entity Type:Organization
Organization Name:DR. DONALD J FORNACE DO FACC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:FORNACE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:386-441-6636
Mailing Address - Street 1:1184 OCEAN SHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32176-3763
Mailing Address - Country:US
Mailing Address - Phone:386-441-6636
Mailing Address - Fax:386-441-6680
Practice Address - Street 1:1184 OCEAN SHORE BLVD
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32176-3760
Practice Address - Country:US
Practice Address - Phone:386-441-6636
Practice Address - Fax:386-441-6680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-06
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL048431800Medicaid
FL048431800Medicaid