Provider Demographics
NPI:1457307613
Name:FORTENBERRY, PHILLIP L (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:L
Last Name:FORTENBERRY
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 1:311 CAMDEN ST
Mailing Address - Street 2:SUITE 208
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78215-2012
Mailing Address - Country:US
Mailing Address - Phone:210-892-0228
Mailing Address - Fax:210-694-0035
Practice Address - Street 1:311 CAMDEN ST
Practice Address - Street 2:SUITE 208
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78215-2012
Practice Address - Country:US
Practice Address - Phone:210-892-0228
Practice Address - Fax:210-455-0169
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL53362085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX173424603Medicaid
TX8G0243Medicare ID - Type Unspecified
TX173424603Medicaid