Basic Information
| Provider Information | |||||||||
| NPI: | 1649432766 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORTUNE | ||||||||
| FirstName: | REGINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | D.O | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 FRANKLIN AVE | ||||||||
| Address2: | LONG ISLAND JEWISH VALLEY STREAM | ||||||||
| City: | VALLEY STREAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5162566000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 FRANKLIN AVE | ||||||||
| Address2: | |||||||||
| City: | VALLEY STREAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115802145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146812560 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2008 | ||||||||
| LastUpdateDate: | 01/13/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 251171 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.