Provider Demographics
NPI:1740390053
Name:FORTIER, KEITH (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:FORTIER
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 1:594 COPENHAGEN RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:VT
Mailing Address - Zip Code:05819-9055
Mailing Address - Country:US
Mailing Address - Phone:802-748-8573
Mailing Address - Fax:707-734-8573
Practice Address - Street 1:594 COPENHAGEN RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:VT
Practice Address - Zip Code:05819-9055
Practice Address - Country:US
Practice Address - Phone:802-748-8573
Practice Address - Fax:707-734-8573
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0006155207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0007981Medicaid
VT0007981Medicaid
VTB85467Medicare UPIN