Provider Demographics
NPI:1639644487
Name:FORTUNE, RICHARD D
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:D
Last Name:FORTUNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 BALTIMORE ANNAPOLIS BLVD STE 111
Mailing Address - Street 2:
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-3956
Mailing Address - Country:US
Mailing Address - Phone:410-544-2500
Mailing Address - Fax:
Practice Address - Street 1:645 BALTIMORE ANNAPOLIS BLVD STE 111
Practice Address - Street 2:
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146-3956
Practice Address - Country:US
Practice Address - Phone:410-544-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-09
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant