Provider Demographics
NPI:1992476675
Name:FORTIER, MARITERE (IDHS)
Entity type:Individual
Prefix:
First Name:MARITERE
Middle Name:
Last Name:FORTIER
Suffix:
Gender:F
Credentials:IDHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15100 RESCUE WAY
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33762-3502
Mailing Address - Country:US
Mailing Address - Phone:727-532-2230
Mailing Address - Fax:727-532-2231
Practice Address - Street 1:15100 RESCUE WAY
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33762-3502
Practice Address - Country:US
Practice Address - Phone:727-532-2230
Practice Address - Fax:727-532-2231
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
1397074753OtherDOD ID NUMBER