Provider Demographics
NPI:1497296537
Name:FORTSON, BENJAMIN DALE (MPO, CPO)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:DALE
Last Name:FORTSON
Suffix:
Gender:M
Credentials:MPO, CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15200 SHADY GROVE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3218
Mailing Address - Country:US
Mailing Address - Phone:240-261-4229
Mailing Address - Fax:240-261-4489
Practice Address - Street 1:15200 SHADY GROVE RD STE 102
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3218
Practice Address - Country:US
Practice Address - Phone:240-261-4229
Practice Address - Fax:240-261-4489
Is Sole Proprietor?:No
Enumeration Date:2017-03-08
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DECO005694222Z00000X
DECPO04027224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist