Provider Demographics
NPI:1174508436
Name:FORTUNATO, VINCENT P (MD)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:P
Last Name:FORTUNATO
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:10004 KENNERLY RD
Mailing Address - Street 2:SUITE #255A
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2141
Mailing Address - Country:US
Mailing Address - Phone:314-843-5140
Mailing Address - Fax:314-843-8010
Practice Address - Street 1:2325 DOUGHERTY FERRY RD STE 104
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-3356
Practice Address - Country:US
Practice Address - Phone:148-216-8893
Practice Address - Fax:314-821-1887
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-09
Last Update Date:2020-08-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MOR1J64207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO110080662OtherRAILROAD MEDICARE
MO206760100Medicaid
MO431650657OtherCIGNA HEALTHCARE
MO21532OtherBLUE CROSS
MO9499441OtherUNITED HEALTHCARE
MO173933OtherHEALTHLINK
MO4084340OtherAETNA
MO21532OtherBLUE CROSS
MO110080662OtherRAILROAD MEDICARE