Provider Demographics
NPI:1336368190
Name:FORTALEZA, PAUL (DO)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
Last Name:FORTALEZA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6350 LAUREL CANYON BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-3278
Mailing Address - Country:US
Mailing Address - Phone:818-325-2090
Mailing Address - Fax:
Practice Address - Street 1:6350 LAUREL CANYON BLVD STE 205
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-3278
Practice Address - Country:US
Practice Address - Phone:818-325-2090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6703207P00000X, 207QG0300X
NVDO2271207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine