Provider Demographics
NPI:1225423635
Name:FORTIN, DAN
Entity Type:Individual
Prefix:MR
First Name:DAN
Middle Name:
Last Name:FORTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2618 ROSEBUSH RD
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-5521
Mailing Address - Country:US
Mailing Address - Phone:334-333-0488
Mailing Address - Fax:
Practice Address - Street 1:2618 ROSEBUSH RD
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-5521
Practice Address - Country:US
Practice Address - Phone:334-333-0488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-02
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS10409390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program