Provider Demographics
NPI:1790963387
Name:FORNARIS, ERNEST A (MD)
Entity Type:Individual
Prefix:
First Name:ERNEST
Middle Name:A
Last Name:FORNARIS
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:PO BOX 1239
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099-1239
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6802 PARAGON PL STE OFC417
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-1644
Practice Address - Country:US
Practice Address - Phone:804-687-4793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-05
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101027358207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA111949751OtherRAILROAD MEDICARE
VA041012OtherANTHEM
VA6088406Medicaid
VAB05895Medicare UPIN
VA111949751OtherRAILROAD MEDICARE