Provider Demographics
NPI:1326104829
Name:FORTMANN, STEPHEN PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:PAUL
Last Name:FORTMANN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 N INTERSTATE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1098
Mailing Address - Country:US
Mailing Address - Phone:503-335-2459
Mailing Address - Fax:503-335-2428
Practice Address - Street 1:3800 N INTERSTATE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1098
Practice Address - Country:US
Practice Address - Phone:503-335-2459
Practice Address - Fax:503-335-2428
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29702207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA44123Medicare UPIN