Provider Demographics
NPI:1659369304
Name:FORTLAGE, DONALD W
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:W
Last Name:FORTLAGE
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:DONALD
Other - Middle Name:W
Other - Last Name:FORTLAGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, FAAP
Mailing Address - Street 1:10202 SE 32ND AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-3610
Mailing Address - Country:US
Mailing Address - Phone:503-653-0770
Mailing Address - Fax:503-653-0844
Practice Address - Street 1:10202 SE 32ND AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-3610
Practice Address - Country:US
Practice Address - Phone:503-653-0770
Practice Address - Fax:503-653-0844
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD07219208000000X
WAMD00021724208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR062844Medicaid
ORD95253000001OtherGOOD HEALTH PLAN