Provider Demographics
NPI:1760584593
Name:FORTUNATE, BRENDA R (DO)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:R
Last Name:FORTUNATE
Suffix:
Gender:F
Credentials:DO
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Mailing Address - Street 1:2462 E HILL RD
Mailing Address - Street 2:STE 1
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-5427
Mailing Address - Country:US
Mailing Address - Phone:810-695-1234
Mailing Address - Fax:810-603-3182
Practice Address - Street 1:2462 E HILL RD
Practice Address - Street 2:SUITE 1
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-5064
Practice Address - Country:US
Practice Address - Phone:810-695-1234
Practice Address - Fax:810-603-3182
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2011-11-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5101008905207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4673868Medicaid
MI4673868Medicaid
MIM23560025Medicare PIN