Provider Demographics
NPI:1235521923
Name:FORTENBERRY, WILLIAM PHILLIP JR
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:PHILLIP
Last Name:FORTENBERRY
Suffix:JR
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 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-264-6000
Mailing Address - Fax:
Practice Address - Street 1:50 PARKWAY LN
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465-3035
Practice Address - Country:US
Practice Address - Phone:601-544-7404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-04
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS28846207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine