Provider Demographics
NPI:1659572089
Name:FORTUNE, TARYN (MD)
Entity Type:Individual
Prefix:DR
First Name:TARYN
Middle Name:
Last Name:FORTUNE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8555 16TH ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-2816
Mailing Address - Country:US
Mailing Address - Phone:301-562-7200
Mailing Address - Fax:
Practice Address - Street 1:5454 WISCONSIN AVE
Practice Address - Street 2:SUITE 1720
Practice Address - City:CHEVY CHASE
Practice Address - State:MD
Practice Address - Zip Code:20815-6901
Practice Address - Country:US
Practice Address - Phone:301-562-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN17513390200000X
MDD00713302084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD0071330OtherSTATE MEDICAL LICENSE