Provider Demographics
NPI:1982022976
Name:FORTY, THERESA VICTORIA (DO)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:VICTORIA
Last Name:FORTY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11885 E 12 MILE RD STE 300A
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-3467
Mailing Address - Country:US
Mailing Address - Phone:586-582-6630
Mailing Address - Fax:586-582-6631
Practice Address - Street 1:1900 ELECTRIC RD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153
Practice Address - Country:US
Practice Address - Phone:540-776-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-07
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101020889207R00000X
VA0102205314207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine