Basic Information
| Provider Information | |||||||||
| NPI: | 1235159344 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORTEZA | ||||||||
| FirstName: | ALEJANDRO | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4960 SW 72ND AVE | ||||||||
| Address2: | SUITE 406 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331555544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056625200 | ||||||||
| FaxNumber: | 3056671275 | ||||||||
| Practice Location | |||||||||
| Address1: | 4960 SW 72ND AVE | ||||||||
| Address2: | SUITE 406 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331555544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056625200 | ||||||||
| FaxNumber: | 3056671275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 10/26/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | ME63972 | FL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084V0102X | 0063972 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Vascular Neurology |
ID Information
| ID | Type | State | Issuer | Description | 3740749 | 05 | FL | MEDICAID | 3740749-00 | 05 | FL | MEDICAID |