Provider Demographics
NPI:1689025702
Name:FORTINI, MARY BERNADETTE (DO)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:BERNADETTE
Last Name:FORTINI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:982185 NEBRASKA MEDICAL CTR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-2185
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:81 N MARIO CAPECCHI DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1125
Practice Address - Country:US
Practice Address - Phone:801-213-3599
Practice Address - Fax:015-853-7898
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-30
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE7826208000000X
UT12831176-12042080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
No208000000XAllopathic & Osteopathic PhysiciansPediatrics