Provider Demographics
NPI:1235319484
Name:JOHN J. FORTIER, M.D.
Entity Type:Organization
Organization Name:JOHN J. FORTIER, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:COCKRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-284-3777
Mailing Address - Street 1:1001 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-4110
Mailing Address - Country:US
Mailing Address - Phone:626-284-3111
Mailing Address - Fax:626-284-1002
Practice Address - Street 1:1001 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-4110
Practice Address - Country:US
Practice Address - Phone:626-284-3111
Practice Address - Fax:626-284-1002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA16184207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAYYY43019YMedicaid
CAA20421Medicare UPIN
CAYYY43019YMedicaid
W2408Medicare PIN