Provider Demographics
NPI:1386618692
Name:FORTIN, AUGUSTE H VI (MD)
Entity type:Individual
Prefix:DR
First Name:AUGUSTE
Middle Name:H
Last Name:FORTIN
Suffix:VI
Gender:M
Credentials:MD
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Mailing Address - Street 1:1450 CHAPEL ST
Mailing Address - Street 2:ADULT PRIMARY CARE CENTER
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-4405
Mailing Address - Country:US
Mailing Address - Phone:203-789-4094
Mailing Address - Fax:203-789-3007
Practice Address - Street 1:1450 CHAPEL ST
Practice Address - Street 2:ADULT PRIMARY CARE CENTER
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-4405
Practice Address - Country:US
Practice Address - Phone:203-789-4044
Practice Address - Fax:203-789-3007
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2015-05-18
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Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT034714207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001347146Medicaid
F34311Medicare UPIN
CT110008084Medicare ID - Type Unspecified