Basic Information
| Provider Information | |||||||||
| NPI: | 1538255823 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORTSON | ||||||||
| FirstName: | DARRYL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | M D | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15645 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891145645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022438500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2704 N TENAYA WAY | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891280424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022438500 | ||||||||
| FaxNumber: | 7023638195 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 01/17/2017 | ||||||||
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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 | 207Q00000X | 01037803 | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 01037803A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 15697 | NV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200004090B | 05 | IN | MEDICAID | V112580-V112581 | 01 | NV | PTAN | OTHER | V113132 | 01 | NV | SMA MEDICARE | OTHER | 000000359839 | 01 | IN | ANTHEM, BC/BS PROVIDER | OTHER |