Provider Demographics
NPI:1568537538
Name:FORTES, WILLIEFRED M (MD)
Entity Type:Individual
Prefix:MR
First Name:WILLIEFRED
Middle Name:M
Last Name:FORTES
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 1:5050 NE HOYT
Mailing Address - Street 2:#414
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213
Mailing Address - Country:US
Mailing Address - Phone:503-235-5724
Mailing Address - Fax:503-254-7892
Practice Address - Street 1:5050 NE HOYT
Practice Address - Street 2:#414
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213
Practice Address - Country:US
Practice Address - Phone:503-235-5724
Practice Address - Fax:503-254-7892
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD19912208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
R0000BLBSWMedicare ID - Type Unspecified
G27853Medicare UPIN