Provider Demographics
NPI:1841292612
Name:FORTIN, JOSEPH D (DO)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:D
Last Name:FORTIN
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 1:9502 LIMA ROAD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46818-9270
Mailing Address - Country:US
Mailing Address - Phone:260-459-7313
Mailing Address - Fax:260-436-0628
Practice Address - Street 1:9502 LIMA ROAD
Practice Address - Street 2:STE 103
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46818-9270
Practice Address - Country:US
Practice Address - Phone:260-459-7313
Practice Address - Fax:260-436-0628
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001553A208100000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200024910AMedicaid
IN250008768OtherRR MEDICARE
IN200024910AMedicaid
IN669740BMedicare PIN
IN250008768OtherRR MEDICARE