Provider Demographics
NPI:1760519946
Name:FORTENBACHER, DAN LEE (OD)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:LEE
Last Name:FORTENBACHER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2908 DIVISION STREET
Mailing Address - Street 2:
Mailing Address - City:ST JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085
Mailing Address - Country:US
Mailing Address - Phone:269-983-3309
Mailing Address - Fax:269-983-0846
Practice Address - Street 1:2908 DIVISION STREET
Practice Address - Street 2:
Practice Address - City:ST JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085
Practice Address - Country:US
Practice Address - Phone:269-983-3309
Practice Address - Fax:269-983-0846
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002693152W00000X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900A165280OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MIC20444Medicare PIN
MI900A165280OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MIA17615002Medicare PIN
MI0700790001Medicare NSC