Provider Demographics
NPI:1285607986
Name:FORTUNA, RANDALL S (MD)
Entity type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:S
Last Name:FORTUNA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11175 CAMPUS ST RM 21121
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92350-1700
Mailing Address - Country:US
Mailing Address - Phone:095-585-9599
Mailing Address - Fax:909-558-0348
Practice Address - Street 1:11234 ANDERSON ST # 7100
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2804
Practice Address - Country:US
Practice Address - Phone:909-558-4200
Practice Address - Fax:909-558-2401
Is Sole Proprietor?:No
Enumeration Date:2006-02-12
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361097642086S0129X, 208G00000X
IL036-1097642086S0129X
AZ49534208G00000X
CAA68643208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL07215075OtherBLUE SHIELD PROVIDER NUMB
IL036109764Medicaid
ILIL0138OtherJOHN DEERE
AZ934932Medicaid
ILP00038024/CA5138OtherRAILROAD MEDICARE
IL07215075OtherBLUE SHIELD PROVIDER NUMB
ILK00310Medicare PIN
AZ934932Medicaid