Provider Demographics
NPI:1386131787
Name:FORTSON, VICTOR
Entity type:Individual
Prefix:MR
First Name:VICTOR
Middle Name:
Last Name:FORTSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19295 N 3RD ST STE 2
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-8897
Mailing Address - Country:US
Mailing Address - Phone:985-400-5901
Mailing Address - Fax:
Practice Address - Street 1:19295 N 3RD ST STE 2
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-8897
Practice Address - Country:US
Practice Address - Phone:985-400-5901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-20
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator