Provider Demographics
NPI:1114998473
Name:JAYNE S FORTSON, MD
Entity Type:Organization
Organization Name:JAYNE S FORTSON, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAYNE
Authorized Official - Middle Name:S
Authorized Official - Last Name:FORTSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-563-3204
Mailing Address - Street 1:2401 E 42ND AVE
Mailing Address - Street 2:STE 301
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5205
Mailing Address - Country:US
Mailing Address - Phone:907-563-3204
Mailing Address - Fax:907-563-4283
Practice Address - Street 1:2401 E 42ND AVE
Practice Address - Street 2:STE 301
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5205
Practice Address - Country:US
Practice Address - Phone:907-563-3204
Practice Address - Fax:907-563-4283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-26
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA2600207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK150346Medicare ID - Type Unspecified