Provider Demographics
NPI:1871507780
Name:FORTALEZA-DAWSON, THERESA REDOBLE (MD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:REDOBLE
Last Name:FORTALEZA-DAWSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6278 N FEDERAL HWY
Mailing Address - Street 2:#183
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-1916
Mailing Address - Country:US
Mailing Address - Phone:954-938-8998
Mailing Address - Fax:954-938-8984
Practice Address - Street 1:2006 NE 49TH ST
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4524
Practice Address - Country:US
Practice Address - Phone:954-938-8998
Practice Address - Fax:954-938-8984
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81298207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG86030Medicare UPIN