Provider Demographics
NPI:1851459309
Name:FORTUNATO, JOSEPH GARY (DO)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:GARY
Last Name:FORTUNATO
Suffix:
Gender:M
Credentials:DO
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 232
Mailing Address - Street 2:
Mailing Address - City:DADE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33526-0232
Mailing Address - Country:US
Mailing Address - Phone:352-518-2000
Mailing Address - Fax:352-567-5193
Practice Address - Street 1:14027 5TH ST
Practice Address - Street 2:
Practice Address - City:DADE CITY
Practice Address - State:FL
Practice Address - Zip Code:33525-4302
Practice Address - Country:US
Practice Address - Phone:352-518-2000
Practice Address - Fax:352-567-5193
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO18129207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003355300Medicaid