Provider Demographics
NPI:1467413914
Name:FORTSON, MARK WILBUR (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:WILBUR
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 1:2933 WILDERNESS DR
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52001-1535
Mailing Address - Country:US
Mailing Address - Phone:563-557-1414
Mailing Address - Fax:
Practice Address - Street 1:2255 JFK RD
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52002-2846
Practice Address - Country:US
Practice Address - Phone:563-582-4357
Practice Address - Fax:563-582-5718
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA277782084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA35557OtherBLUE CROSS WELLMARK BLUE
IA1065847Medicaid
IAD45364Medicare UPIN
IA1065847Medicaid