Provider Demographics
NPI:1053313718
Name:FORTUNATO, DIANE L (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:L
Last Name:FORTUNATO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2412 QUIRT LN
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33983-2627
Mailing Address - Country:US
Mailing Address - Phone:941-764-9480
Mailing Address - Fax:
Practice Address - Street 1:2412 QUIRT LN
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33983-2627
Practice Address - Country:US
Practice Address - Phone:941-764-9480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2021-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04648600207R00000X
FL63562207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1868501Medicaid
NJC55648Medicare UPIN
NJ454835Medicare ID - Type Unspecified