Provider Demographics
NPI:1831521228
Name:CANDICE D FORTUNATO MD PLLC
Entity type:Organization
Organization Name:CANDICE D FORTUNATO MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CANDICE
Authorized Official - Middle Name:D
Authorized Official - Last Name:FORTUNATO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-450-1717
Mailing Address - Street 1:500 N RAINBOW BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-1061
Mailing Address - Country:US
Mailing Address - Phone:702-450-1717
Mailing Address - Fax:702-941-6740
Practice Address - Street 1:500 N RAINBOW BLVD STE 300
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107-1061
Practice Address - Country:US
Practice Address - Phone:702-450-1717
Practice Address - Fax:702-941-6740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-07
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty