Provider Demographics
NPI:1881667400
Name:DANIEL L FORTMANN MD PC
Entity Type:Organization
Organization Name:DANIEL L FORTMANN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:LUCILLE
Authorized Official - Last Name:FORTMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-233-0141
Mailing Address - Street 1:32281 CAMINO CAPISTRANO
Mailing Address - Street 2:STE C-102
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675
Mailing Address - Country:US
Mailing Address - Phone:949-493-7981
Mailing Address - Fax:949-493-0114
Practice Address - Street 1:32281 CAMINO CAPISTRANO
Practice Address - Street 2:STE C-102
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675
Practice Address - Country:US
Practice Address - Phone:949-493-7981
Practice Address - Fax:949-493-0114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37462207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA37462OOtherMEDICARE PPIN
1114197142OtherNPI TYPE 1
CA1881667400OtherNPI TYPE II
CA00A374620OtherMEDI-CAL
CA00A374620OtherMEDI-CAL
W16456Medicare ID - Type Unspecified