Provider Demographics
NPI:1457452591
Name:FORTSON, MARK ROUTON (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ROUTON
Last Name:FORTSON
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 1:2200 HAMILTON RD STE B
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-8856
Mailing Address - Country:US
Mailing Address - Phone:706-655-8800
Mailing Address - Fax:706-940-9767
Practice Address - Street 1:2200 HAMILTON RD STE B
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-8856
Practice Address - Country:US
Practice Address - Phone:706-655-8800
Practice Address - Fax:706-940-9767
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA24937207RG0100X
GA024937207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000274612Medicaid
GA10BDHLTOtherMEDICARE PTAN
GA2744612GMedicaid