Provider Demographics
NPI:1154416220
Name:FORTNER, WILLIAM P (OD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:P
Last Name:FORTNER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 88
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:TN
Mailing Address - Zip Code:38382-0088
Mailing Address - Country:US
Mailing Address - Phone:731-855-0811
Mailing Address - Fax:731-855-4725
Practice Address - Street 1:107 E 1ST ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:TN
Practice Address - Zip Code:38382-1841
Practice Address - Country:US
Practice Address - Phone:731-855-0811
Practice Address - Fax:731-855-4725
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD435152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN9200OtherTLC PIN
TN3596167Medicare PIN
TN9200OtherTLC PIN
TN0455670001Medicare NSC