Basic Information
| Provider Information | |||||||||
| NPI: | 1881678290 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORTU | ||||||||
| FirstName: | JESUSA MILALAINE | ||||||||
| MiddleName: | TERRADO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3901 W STATE ROAD 84 | ||||||||
| Address2: | #107 | ||||||||
| City: | DAVIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333128827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9545302660 | ||||||||
| FaxNumber: | 9545302660 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 JOE DIMAGGIO DR | ||||||||
| Address2: | PEDIATRIC EMERGENCY DEPARTMENT | ||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330215426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549872000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2005 | ||||||||
| LastUpdateDate: | 03/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 38856 | KY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 6409176200 | 05 | FL | MEDICAID | 6409176200 | 05 | KY | MEDICAID |