Provider Demographics
NPI:1891715363
Name:FORTUNE, JUNIOR FORBES (PA)
Entity Type:Individual
Prefix:
First Name:JUNIOR
Middle Name:FORBES
Last Name:FORTUNE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11161 CRENSHAW BLVD
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90303-2338
Mailing Address - Country:US
Mailing Address - Phone:310-419-1067
Mailing Address - Fax:
Practice Address - Street 1:11161 CRENSHAW BLVD
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90303-2338
Practice Address - Country:US
Practice Address - Phone:310-419-1067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13021174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR40781Medicare UPIN