Provider Demographics
NPI:1962580035
Name:FORTENKO, ANATOLIY S (MD)
Entity type:Individual
Prefix:
First Name:ANATOLIY
Middle Name:S
Last Name:FORTENKO
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 1:1800 HARRISON ST FL 7
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-3466
Mailing Address - Country:US
Mailing Address - Phone:510-625-6262
Mailing Address - Fax:
Practice Address - Street 1:200 MUIR RD
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-4614
Practice Address - Country:US
Practice Address - Phone:925-372-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79403208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A794030Medicaid
CA00A794030Medicaid
H95785Medicare UPIN