MASSUDA, FORTUNEE (DPM)

Provider Demographics

• NPI: 1952307019
• Name: MASSUDA, FORTUNEE (DPM)
• Entity Type: Individual
• First Name: FORTUNEE
• Last Name: MASSUDA
• Gender: F
• Credentials: DPM
• Mailing Address - Street 1: 9933 S WESTERN AVE
• Mailing Address - Street 2: STE 102
• Mailing Address - City: CHICAGO
• Mailing Address - State: IL
• Mailing Address - Zip Code: 60643-1810
• Mailing Address - Country: US
• Mailing Address - Phone: 773-445-8700
• Mailing Address - Fax: 773-445-4646
• Practice Address - Street 1: 1644 E 53RD ST
• Practice Address - City: CHICAGO
• Practice Address - State: IL
• Practice Address - Zip Code: 60615-4210
• Practice Address - Country: US
• Practice Address - Phone: 773-752-2111
• Practice Address - Fax: 773-752-6703
• Is Sole Proprietor?: Yes
• Enumeration Date: 2005-06-23
• Last Update Date: 2009-11-12

Provider Licenses

State	License ID	Taxonomies
IL	016-003113	213EP1101X, 213ES0131X
IL	016003113	213ES0103X, 213E00000X, 213EP0504X
IN	07000479A	213EP1101X, 213ES0131X, 213ES0103X, 213E00000X, 213EP0504X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	213ES0103X	Podiatric Medicine & Surgery Service Providers	Podiatrist	Foot & Ankle Surgery
No	213EP1101X	Podiatric Medicine & Surgery Service Providers	Podiatrist	Primary Podiatric Medicine
No	213ES0131X	Podiatric Medicine & Surgery Service Providers	Podiatrist	Foot Surgery
No	213E00000X	Podiatric Medicine & Surgery Service Providers	Podiatrist
No	213EP0504X	Podiatric Medicine & Surgery Service Providers	Podiatrist	Public Medicine

Provider Identifiers

State	Identifier ID	ID Type	Issuer
IN	200-120890	Medicaid
IN	000000314554	Other	ANTHEM
IL	00000246499 65	Other	UNITED HEALTHCARE
IL	1374072-010	Other	CIGNA
IL	4029837	Other	AETNA
IL	L22239	Other	PIN NUMBER
IL	1374072-002	Other	CIGNA
IL	P15865	Medicare PIN
IL	4029837	Other	AETNA
IL	T37552	Medicare UPIN
IL	P15866	Medicare PIN
IL	L78200	Medicare PIN
IL	L22760	Medicare PIN
IL	L22239	Other	PIN NUMBER
IL	1374072-010	Other	CIGNA
IL	1374072-002	Other	CIGNA
IN	200-120890	Medicaid
IL	0852860002	Medicare NSC
IN	000000314554	Other	ANTHEM
IL	4951050003	Medicare NSC
IL	0852850007	Medicare NSC
IN	210580C	Medicare PIN
IN	5007670001	Medicare NSC
IL	5506750001	Medicare NSC
IL	4951050002	Medicare NSC