Provider Demographics
NPI:1811202328
Name:LAWRENCEJFORTUNAMDPA
Entity Type:Organization
Organization Name:LAWRENCEJFORTUNAMDPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:FORTUNA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-876-0945
Mailing Address - Street 1:718 E MCNAB RD
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33060-9430
Mailing Address - Country:US
Mailing Address - Phone:954-876-0945
Mailing Address - Fax:954-876-0965
Practice Address - Street 1:718 E MCNAB RD
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33060-9430
Practice Address - Country:US
Practice Address - Phone:954-876-0945
Practice Address - Fax:954-876-0965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME46908261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL79969Medicare UPIN