Provider Demographics
NPI:1104867381
Name:FORTICH, JAIRO ALFREDO (MD)
Entity Type:Individual
Prefix:DR
First Name:JAIRO
Middle Name:ALFREDO
Last Name:FORTICH
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 1:140 MARKET PLACE BLVD STE E
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-2337
Mailing Address - Country:US
Mailing Address - Phone:865-212-2211
Mailing Address - Fax:833-314-0589
Practice Address - Street 1:140 MARKET PLACE BLVD STE E
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-2337
Practice Address - Country:US
Practice Address - Phone:865-212-2211
Practice Address - Fax:833-314-0589
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN40307207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1533218Medicaid
TN4124436OtherBCBS