Provider Demographics
NPI:1043636202
Name:FORTNER, GRADY AUSBUR (MD)
Entity Type:Individual
Prefix:DR
First Name:GRADY
Middle Name:AUSBUR
Last Name:FORTNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25578
Mailing Address - Street 2:
Mailing Address - City:BARRIGADA
Mailing Address - State:GU
Mailing Address - Zip Code:96921-5578
Mailing Address - Country:US
Mailing Address - Phone:671-480-7934
Mailing Address - Fax:
Practice Address - Street 1:554 KEILY STREET
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32212
Practice Address - Country:US
Practice Address - Phone:757-953-7550
Practice Address - Fax:757-953-7560
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-12
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116027243207P00000X
GUM-2191207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine