Provider Demographics
NPI:1891768289
Name:FORTNER, GARY DEE (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:DEE
Last Name:FORTNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 N FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-3159
Mailing Address - Country:US
Mailing Address - Phone:918-341-1044
Mailing Address - Fax:918-341-7443
Practice Address - Street 1:1408 N FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-3159
Practice Address - Country:US
Practice Address - Phone:918-341-1044
Practice Address - Fax:918-341-7443
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12540207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100150500AMedicaid
C94936Medicare UPIN