Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 34-011726 | OH |
N | 207QS0010X | Family Doctor - Sports Medicine | 34.011726 | OH |
NPI | 1073889903 |
---|---|
Provider Name | Craig William Fortman |
First Address | Dublin, OH 43016-6102 |
Second Address | Grove City, OH 43123-3993 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/03/2012 |
Last Update Date | 25/01/2022 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0126633 | (05) | OH |