Provider Demographics
NPI:1972592822
Name:FORTIER, LAWRENCE J I (MD)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:J
Last Name:FORTIER
Suffix:I
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 1:465 SILAS DEANE HWY
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-2134
Mailing Address - Country:US
Mailing Address - Phone:860-529-2500
Mailing Address - Fax:860-529-6899
Practice Address - Street 1:465 SILAS DEANE HWY
Practice Address - Street 2:
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109-2134
Practice Address - Country:US
Practice Address - Phone:860-529-2500
Practice Address - Fax:860-529-6899
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT025854207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010025854CT01OtherANTHEM BC/BS
CT001258540Medicaid
CTB38242Medicare UPIN
CT070000138Medicare ID - Type Unspecified