Provider Demographics
NPI:1861538951
Name:FORTUNE, JAMES EVERETT (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:EVERETT
Last Name:FORTUNE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 847
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38088-0847
Mailing Address - Country:US
Mailing Address - Phone:901-821-0338
Mailing Address - Fax:901-507-8292
Practice Address - Street 1:7580 CLARINGTON CV
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-5657
Practice Address - Country:US
Practice Address - Phone:662-349-1940
Practice Address - Fax:662-349-3212
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000007792208600000X
MS06635208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00017199Medicaid
MSB03262Medicare UPIN