Provider Demographics
NPI:1124284468
Name:FORTICH, KAROL ENRIQUE (MD)
Entity type:Individual
Prefix:
First Name:KAROL
Middle Name:ENRIQUE
Last Name:FORTICH
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 1:6675 WESTWOOD BLVD STE 475
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32821-6027
Mailing Address - Country:US
Mailing Address - Phone:407-845-0330
Mailing Address - Fax:888-972-1752
Practice Address - Street 1:199 SE AVENUE K
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880
Practice Address - Country:US
Practice Address - Phone:863-299-6700
Practice Address - Fax:863-299-6359
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.010862207R00000X
FLME107259207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME107259OtherMEDICINE DOCTOR LIC