Provider Demographics
NPI:1386044477
Name:FORTUNA MEDICAL GROUP
Entity Type:Organization
Organization Name:FORTUNA MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:OSWALD
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-342-7046
Mailing Address - Street 1:11510 S FORTUNA RD
Mailing Address - Street 2:STE A
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85367-7843
Mailing Address - Country:US
Mailing Address - Phone:928-342-7046
Mailing Address - Fax:928-342-7018
Practice Address - Street 1:11510 S FORTUNA RD
Practice Address - Street 2:SUITE A
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85367-7843
Practice Address - Country:US
Practice Address - Phone:928-342-7046
Practice Address - Fax:928-342-7018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-26
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center