Provider Demographics
NPI:1538255823
Name:FORTSON, DARRYL L (M D)
Entity type:Individual
Prefix:
First Name:DARRYL
Middle Name:L
Last Name:FORTSON
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15645
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:702-243-8500
Mailing Address - Fax:
Practice Address - Street 1:2704 N TENAYA WAY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0424
Practice Address - Country:US
Practice Address - Phone:702-243-8500
Practice Address - Fax:702-363-8195
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037803207Q00000X
IN01037803A207Q00000X
NV15697207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200004090BMedicaid
NVV112580-V112581OtherPTAN
NVV113132OtherSMA MEDICARE
IN000000359839OtherANTHEM, BC/BS PROVIDER
IN000000359839OtherANTHEM, BC/BS PROVIDER