Provider Demographics
NPI:1720588791
Name:FORTGANG, ALEXANDER J (DO)
Entity type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:J
Last Name:FORTGANG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7600 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-6217
Mailing Address - Country:US
Mailing Address - Phone:201-854-5000
Mailing Address - Fax:
Practice Address - Street 1:350 ENGLE ST FL 6
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-1808
Practice Address - Country:US
Practice Address - Phone:201-608-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-16
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB11886800208600000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1014161Medicaid