Provider Demographics
NPI:1720121585
Name:FORTUNE, BRETT EMERSON (MD)
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:EMERSON
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 1:1305 YORK AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-5663
Mailing Address - Country:US
Mailing Address - Phone:646-962-5483
Mailing Address - Fax:
Practice Address - Street 1:1305 YORK AVE FL 4
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-5663
Practice Address - Country:US
Practice Address - Phone:646-962-5483
Practice Address - Fax:646-962-0363
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35088963207R00000X
CT051154207RG0100X
NY283730207RI0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0008XAllopathic & Osteopathic PhysiciansInternal MedicineHepatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2729917Medicaid
OHI73335Medicare UPIN
OHFO4207641Medicare PIN