Basic Information
| Provider Information | |||||||||
| NPI: | 1124284468 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORTICH | ||||||||
| FirstName: | KAROL | ||||||||
| MiddleName: | ENRIQUE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 WEBB DR | ||||||||
| Address2: | |||||||||
| City: | DAVENPORT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338373962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8635881424 | ||||||||
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| Practice Location | |||||||||
| Address1: | 199 SE AVENUE K | ||||||||
| Address2: | |||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632996700 | ||||||||
| FaxNumber: | 8632996359 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2008 | ||||||||
| LastUpdateDate: | 09/29/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 57.010862 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | ME107259 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | ME107259 | 01 | FL | MEDICINE DOCTOR LIC | OTHER |