Provider Demographics
NPI:1134387186
Name:FORTUNE, MARK ANTHONY (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:FORTUNE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2463 S KIHEI RD # 406
Mailing Address - Street 2:
Mailing Address - City:KIHEI
Mailing Address - State:HI
Mailing Address - Zip Code:96753-7285
Mailing Address - Country:US
Mailing Address - Phone:808-870-2544
Mailing Address - Fax:808-891-0084
Practice Address - Street 1:2463 S KIHEI RD # 406
Practice Address - Street 2:
Practice Address - City:KIHEI
Practice Address - State:HI
Practice Address - Zip Code:96753-7285
Practice Address - Country:US
Practice Address - Phone:808-870-2544
Practice Address - Fax:808-891-0084
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
HIDOS734207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG41422Medicare UPIN