Provider Demographics
NPI:1376530816
Name:FORTENBERRY, FRAZIER T JR (MD)
Entity Type:Individual
Prefix:DR
First Name:FRAZIER
Middle Name:T
Last Name:FORTENBERRY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:630 PETER JEFFERSON PKWY
Mailing Address - Street 2:SUITE 135
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22911-8605
Mailing Address - Country:US
Mailing Address - Phone:434-244-5722
Mailing Address - Fax:434-244-5723
Practice Address - Street 1:630 PETER JEFFERSON PKWY
Practice Address - Street 2:SUITE 135
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-8605
Practice Address - Country:US
Practice Address - Phone:434-244-5722
Practice Address - Fax:434-244-5723
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2011-07-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0101044989208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA14120OtherCOMMUNITY HEALTH
VA23555OtherCIGNA
VA461522OtherANTHEM SERVICES
VAP00003207OtherMEDICARE PIN
VA367104OtherMAMSI
VA204175OtherSOUTHERN HEALTH
VA340000300OtherMEDICARE
VA23555OtherCIGNA
VA367104OtherMAMSI