Provider Demographics
NPI:1205836194
Name:FORTSON, JAMES (MD MBA MPH FACS)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:
Last Name:FORTSON
Suffix:
Gender:M
Credentials:MD MBA MPH FACS
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 838
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30085-0838
Mailing Address - Country:US
Mailing Address - Phone:404-768-9351
Mailing Address - Fax:404-768-2530
Practice Address - Street 1:1136 CLEVELAND AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-3618
Practice Address - Country:US
Practice Address - Phone:404-768-9350
Practice Address - Fax:404-768-2530
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043205207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000738603BMedicaid
GA000738603BMedicaid
A02767Medicare UPIN