Provider Demographics
NPI:1891781126
Name:FORTNER, FLORENDA L (MD)
Entity Type:Individual
Prefix:
First Name:FLORENDA
Middle Name:L
Last Name:FORTNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:5535 GRAND BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652
Mailing Address - Country:US
Mailing Address - Phone:727-841-0700
Mailing Address - Fax:727-841-6969
Practice Address - Street 1:5535 GRAND BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652
Practice Address - Country:US
Practice Address - Phone:727-841-0700
Practice Address - Fax:727-841-6969
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-22
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME86987207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270609100Medicaid
FL270609100Medicaid
I17953Medicare UPIN