Provider Demographics
NPI:1639157407
Name:FORTUNATO, JOSEPH DOMENIC (DD)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:DOMENIC
Last Name:FORTUNATO
Suffix:
Gender:M
Credentials:DD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6301 N KEYSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-2156
Mailing Address - Country:US
Mailing Address - Phone:317-257-2225
Mailing Address - Fax:317-257-0646
Practice Address - Street 1:6301 N KEYSTONE AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-2156
Practice Address - Country:US
Practice Address - Phone:317-257-2225
Practice Address - Fax:317-257-0646
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001070111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN4355508OtherAETNA
IN000000091939OtherANTHEM BC/BS
INT35038Medicare UPIN
IN276390AMedicare ID - Type Unspecified