Provider Demographics
NPI:1609135243
Name:FUORTES, MICHAELANGELO GREGORY (MD, PHD)
Entity Type:Individual
Prefix:
First Name:MICHAELANGELO
Middle Name:GREGORY
Last Name:FUORTES
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1948 1ST AVE NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-5377
Mailing Address - Country:US
Mailing Address - Phone:319-364-0121
Mailing Address - Fax:
Practice Address - Street 1:1948 1ST AVE NE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402
Practice Address - Country:US
Practice Address - Phone:319-364-0121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-15
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-442132085R0202X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program