Provider Demographics
NPI:1174339972
Name:FORTIN, EDGAR FIRME (NP)
Entity type:Individual
Prefix:MR
First Name:EDGAR
Middle Name:FIRME
Last Name:FORTIN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3498 LINDA VISTA RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-1440
Mailing Address - Country:US
Mailing Address - Phone:323-717-2139
Mailing Address - Fax:
Practice Address - Street 1:3498 LINDA VISTA RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-1440
Practice Address - Country:US
Practice Address - Phone:323-717-2139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-06
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95028352207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine