Individual
DONALD W. FORTLAGE
Active
Sole proprietor
Provider details
NPI number
Gender
Man
Contact information
Practice address
10202 SE 32ND AVE, SUITE 201, MILWAUKIE, OR 97222-3610
(503) 653-0770
(503) 653-0844
Mailing address
10202 SE 32ND AVE, SUITE 201, MILWAUKIE, OR 97222-3610
(503) 653-0770
(503) 653-0844
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
MD00021724
WA
208000000X
Pediatrics Physician
Primary
MD07219
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
062844
—
OR
01
—
D95253000001
GOOD HEALTH PLAN
OR
Enumeration date
10/07/2005
Last updated
07/09/2007
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