Provider Demographics
NPI:1134154388
Name:FORTNER, CORWYN DEAN (MD)
Entity type:Individual
Prefix:
First Name:CORWYN
Middle Name:DEAN
Last Name:FORTNER
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:PO BOX 12938
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30703-7013
Mailing Address - Country:US
Mailing Address - Phone:706-602-7800
Mailing Address - Fax:
Practice Address - Street 1:1035 RED BUD RD NE
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-6010
Practice Address - Country:US
Practice Address - Phone:706-879-4776
Practice Address - Fax:706-879-4781
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO44088207L00000X
TN67209207L00000X
WY7556A207L00000X
CAA87236207L00000X
GA88799207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO23181249Medicaid
CO23181249Medicaid
COCOA102005Medicare PIN