Provider Demographics
NPI:1689841413
Name:SALAS, FORTUNATA SANTOS (MD)
Entity Type:Individual
Prefix:
First Name:FORTUNATA
Middle Name:SANTOS
Last Name:SALAS
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 1:11 VILLAGE GATE ROAD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07882
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 VILLAGE GATE ROAD
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07882
Practice Address - Country:US
Practice Address - Phone:908-689-1946
Practice Address - Fax:908-689-1946
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-12
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02287900207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine