Provider Demographics
NPI:1194788869
Name:FORTENBERRY, JAMES (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:FORTENBERRY
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 1:1575 NORTHEAST EXPY NE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2401
Mailing Address - Country:US
Mailing Address - Phone:404-785-1313
Mailing Address - Fax:404-785-6233
Practice Address - Street 1:1575 NORTHEAST EXPY NE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:GA
Practice Address - Zip Code:30329-2401
Practice Address - Country:US
Practice Address - Phone:404-785-1313
Practice Address - Fax:404-785-6233
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA358752080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00508604CMedicaid
GAE55982Medicare UPIN
GA37BBFDDMedicare ID - Type Unspecified