Provider Demographics
NPI:1962639757
Name:FORTES, MANUEL CORREA (MD)
Entity Type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:CORREA
Last Name:FORTES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2722 MERRILEE DR STE 230
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4400
Mailing Address - Country:US
Mailing Address - Phone:703-698-4488
Mailing Address - Fax:703-204-0116
Practice Address - Street 1:2722 MERRILEE DR STE 230
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4400
Practice Address - Country:US
Practice Address - Phone:703-698-4488
Practice Address - Fax:703-204-0116
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1426652085N0700X
CODR.00671252085R0204X
MDD00748082085R0204X
VA01012657562085R0204X, 2085R0204X
OK296962085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1962639757Medicaid
OK293670YNR6Medicare PIN
OK293670YLG8Medicare PIN
OK293670YPK2Medicare PIN