Provider Demographics
NPI:1255349700
Name:FORTGANG, MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:FORTGANG
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 1:230 SAUGATUCK AVE
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-6401
Mailing Address - Country:US
Mailing Address - Phone:203-739-7532
Mailing Address - Fax:203-743-2610
Practice Address - Street 1:36 TAMARACK AVE
Practice Address - Street 2:PBM 118
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06811-4822
Practice Address - Country:US
Practice Address - Phone:203-739-7532
Practice Address - Fax:203-743-2610
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT027366174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD80878Medicare UPIN