Provider Demographics
NPI:1487784880
Name:FORTMAN, DIANE H (DPM)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:H
Last Name:FORTMAN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2448 ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14217-2244
Mailing Address - Country:US
Mailing Address - Phone:716-875-7878
Mailing Address - Fax:716-875-1240
Practice Address - Street 1:2448 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-2244
Practice Address - Country:US
Practice Address - Phone:716-875-7878
Practice Address - Fax:716-875-1240
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2008-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY38591213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00010252801OtherUNIVERA
NY8906817OtherIHA
0094789OtherGHI
161262434OtherUNITED
NY00897347Medicaid
NY396558OtherWELLCARE
000500702001OtherBCBS
NY00897347Medicaid
161262434OtherUNITED
0094789OtherGHI