Provider Demographics
NPI:1669494480
Name:FORNACE, DONALD JOSEPH (DO FACC)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:JOSEPH
Last Name:FORNACE
Suffix:
Gender:M
Credentials:DO FACC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 HAND AVE
Mailing Address - Street 2:SUITE H
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-8194
Mailing Address - Country:US
Mailing Address - Phone:386-441-6636
Mailing Address - Fax:386-441-6680
Practice Address - Street 1:1400 HAND AVE
Practice Address - Street 2:SUITE H
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-8194
Practice Address - Country:US
Practice Address - Phone:386-441-6636
Practice Address - Fax:386-441-6680
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOS5475207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL048431800Medicaid
FL048431800Medicaid
FL80078Medicare ID - Type Unspecified