Provider Demographics
NPI:1427050426
Name:FORTT, TABITHA (MD)
Entity type:Individual
Prefix:
First Name:TABITHA
Middle Name:
Last Name:FORTT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 HOYT ST
Mailing Address - Street 2:SUITE #4
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-5604
Mailing Address - Country:US
Mailing Address - Phone:203-674-0774
Mailing Address - Fax:203-674-0766
Practice Address - Street 1:23 HOYT ST
Practice Address - Street 2:SUITE #4
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5604
Practice Address - Country:US
Practice Address - Phone:203-674-0774
Practice Address - Fax:203-674-0766
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT037894207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008036735Medicaid
CTH41669Medicare UPIN
CT080001859Medicare PIN