Provider Demographics
NPI:1689721573
Name:FORTGANG, ILANA S (MD)
Entity Type:Individual
Prefix:
First Name:ILANA
Middle Name:S
Last Name:FORTGANG
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:P.O. BOX 1520
Mailing Address - Street 2:
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70073-1520
Mailing Address - Country:US
Mailing Address - Phone:504-349-6423
Mailing Address - Fax:504-934-8097
Practice Address - Street 1:1111 MEDICAL CENTER BLVD.
Practice Address - Street 2:SUITE S-450
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072
Practice Address - Country:US
Practice Address - Phone:504-349-6401
Practice Address - Fax:504-349-6444
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0233582080P0206X
LAMD.0233582080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1499617Medicaid
LA1499617Medicaid
LA4K724Medicare PIN