Provider Demographics
NPI:1841291226
Name:FORTUNATO, MICHAEL ANTHONY (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:FORTUNATO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S HARBOUR ISLAND BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-5925
Mailing Address - Country:US
Mailing Address - Phone:727-322-3439
Mailing Address - Fax:800-928-7449
Practice Address - Street 1:2032 US 1
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-5420
Practice Address - Country:US
Practice Address - Phone:772-213-9614
Practice Address - Fax:772-213-9615
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV14743207Q00000X
FLME143867207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
550357057070OtherANTHEM BCBS
A72586Medicare UPIN
550357057070OtherANTHEM BCBS