Provider Demographics
NPI:1275732935
Name:FORTENBERRY, SANDRA K (OD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:K
Last Name:FORTENBERRY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9725 DATAPOINT DRIVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-2384
Mailing Address - Country:US
Mailing Address - Phone:210-283-6800
Mailing Address - Fax:210-283-6825
Practice Address - Street 1:9725 DATAPOINT DRIVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-2384
Practice Address - Country:US
Practice Address - Phone:210-283-6800
Practice Address - Fax:210-283-6825
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-13
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7062T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1888307305Medicaid
TX1888307305Medicaid