1790733871 NPI number — University of Claifornia San Francisco DR. LISA R FORTUNA MD

Table of content: DR. LISA R FORTUNA MD (NPI 1790733871)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790733871 NPI number — University of Claifornia San Francisco DR. LISA R FORTUNA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
University of Claifornia San Francisco
Provider Last Name:
FORTUNA
Provider First Name:
LISA
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MPH
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790733871
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2618 22nd St.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
San Francisco
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-797-1953
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 Potrero Avenue, 7M8, Zuckerberg San Francisco General Hospital and Trauma Center
Provider Second Line Business Practice Location Address:
UCSF Campus Box 0852
Provider Business Practice Location Address City Name:
San Francisco
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
628-206-5969
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/04/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  210650 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0804X , with the licence number: 210650 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)