Provider Demographics
NPI:1972593705
Name:FORTSON, MICHAEL T (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:FORTSON
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 1:933 BRADBURY DR SE STE 2222
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4375
Mailing Address - Country:US
Mailing Address - Phone:505-272-1476
Mailing Address - Fax:
Practice Address - Street 1:933 BRADBURY DR SE STE 2222
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4375
Practice Address - Country:US
Practice Address - Phone:505-272-1476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA35051207Q00000X
NMMD2020-0323207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52028703002OtherBC/BS GEORGIA
GA080140399OtherMEDICARE RAILROAD
GAE75899Medicare UPIN
GA313963OtherWELLCARE
GA8262OtherKAISER
GA08BDPXJMedicare PIN
GA10033116OtherAMERIGROUP
GA1043500001OtherPEACHSTATE
GA0103319OtherUNITED HEALTHCARE
GA000494942BMedicaid