Provider Demographics
NPI:1215091947
Name:FORTIN, MARY DOUGLAS
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:DOUGLAS
Last Name:FORTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5305 ALAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-5720
Mailing Address - Country:US
Mailing Address - Phone:408-266-6279
Mailing Address - Fax:
Practice Address - Street 1:710 LAWERENCE EXPRESSWAY, DEPT.174
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95051
Practice Address - Country:US
Practice Address - Phone:408-851-1495
Practice Address - Fax:408-851-1499
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT106062251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics