Provider Demographics
NPI:1932271566
Name:FORTUNE, BRAD (OD PHD)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:FORTUNE
Suffix:
Gender:M
Credentials:OD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 NE SECOND AVENUE
Mailing Address - Street 2:3RD FLOOR DISCOVERIES IN SIGHT
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232
Mailing Address - Country:US
Mailing Address - Phone:503-413-1198
Mailing Address - Fax:503-413-5179
Practice Address - Street 1:1040 NW 22ND AVENUE
Practice Address - Street 2:DEVERS EYE INSTITUTE
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210
Practice Address - Country:US
Practice Address - Phone:503-413-1198
Practice Address - Fax:503-413-5179
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2824T152W00000X
CA9833152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR228831Medicaid
OR228831Medicaid