1295795664 NPI number — NATHAN BENJAMIN FORREST D.O.

Table of content: NATHAN BENJAMIN FORREST D.O. (NPI 1295795664)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295795664 NPI number — NATHAN BENJAMIN FORREST D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORREST
Provider First Name:
NATHAN
Provider Middle Name:
BENJAMIN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295795664
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4777 US HIGHWAY 259
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONGVIEW
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75605-7668
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-663-7393
Provider Business Mailing Address Fax Number:
903-663-7394

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6901 MEDICAL PKWY
Provider Second Line Business Practice Location Address:
RADIOLOGY DEPARTMENT
Provider Business Practice Location Address City Name:
WACO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76712-7910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-751-4000
Provider Business Practice Location Address Fax Number:
903-663-7394
Provider Enumeration Date:
03/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  K3576 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00195387 . This is a "RR/MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8W7435 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1046328-05 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1046328-04 . This is a "CSHCN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8P1488 . This is a "BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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