Individual
MR. RANDALL S FORTUNA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
11234 ANDERSON ST # 7100, LOMA LINDA, CA 92354-2804
(909) 558-4200
(909) 558-2401
Mailing address
11175 CAMPUS ST RM 21121, LOMA LINDA, CA 92350-1700
(095) 585-9599
(909) 558-0348
Taxonomy
Speciality
Code
Description
License number
State
2086S0129X
Vascular Surgery Physician
036-109764
IL
2086S0129X
Vascular Surgery Physician
036109764
IL
208G00000X
Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
036109764
IL
208G00000X
Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
49534
AZ
208G00000X
Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
Primary
A68643
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036109764
—
IL
01
—
07215075
BLUE SHIELD PROVIDER NUMB
IL
05
—
934932
—
AZ
01
—
IL0138
JOHN DEERE
IL
01
—
P00038024/CA5138
RAILROAD MEDICARE
IL
Enumeration date
02/12/2006
Last updated
10/31/2023
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