Provider Demographics
NPI:1710998794
Name:FORT, DARRELL LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:DARRELL
Middle Name:LEE
Last Name:FORT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1464 SE KANE ST
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-4235
Mailing Address - Country:US
Mailing Address - Phone:541-957-8570
Mailing Address - Fax:
Practice Address - Street 1:913 NW GARDEN VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-6523
Practice Address - Country:US
Practice Address - Phone:541-440-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY21698174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist