Provider Demographics
NPI:1568567055
Name:VINCENT M FORTANASCE MD, INC
Entity Type:Organization
Organization Name:VINCENT M FORTANASCE MD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:N
Authorized Official - Last Name:SAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-445-8481
Mailing Address - Street 1:289 W HUNTINGTON DR STE 309
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007-3493
Mailing Address - Country:US
Mailing Address - Phone:626-445-8481
Mailing Address - Fax:626-574-9669
Practice Address - Street 1:289 W HUNTINGTON DR STE 309
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91007-3493
Practice Address - Country:US
Practice Address - Phone:626-445-8481
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA259762084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA25976Medicare PIN