Provider Demographics
NPI:1942356720
Name:FORT, PETER ANTHONY (DC)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:ANTHONY
Last Name:FORT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4540 SOUTHSIDE BLVD STE 1101
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-5495
Mailing Address - Country:US
Mailing Address - Phone:904-996-8660
Mailing Address - Fax:904-996-8650
Practice Address - Street 1:4540 SOUTHSIDE BLVD STE 1101
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-5495
Practice Address - Country:US
Practice Address - Phone:904-996-8660
Practice Address - Fax:904-996-8650
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH006468111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL55266AMedicare PIN