Provider Demographics
NPI:1134223274
Name:FORTUNE, THOMAS P (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:P
Last Name:FORTUNE
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 1:101 PARK HILL DRIVE
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401
Mailing Address - Country:US
Mailing Address - Phone:540-371-3010
Mailing Address - Fax:540-899-9821
Practice Address - Street 1:101 PARK HILL DRIVE
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401
Practice Address - Country:US
Practice Address - Phone:540-371-3010
Practice Address - Fax:540-899-9821
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA010103908207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006037402Medicaid
VA110026872OtherRAILROAD
VA00414802OtherAETNA
VA094197OtherANTHEM BCBS
VA110026872OtherRAILROAD
VA110003891Medicare PIN