Provider Demographics
NPI:1033125935
Name:FORSETER, SHANON ALEX (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANON
Middle Name:ALEX
Last Name:FORSETER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5314 STONEYBROOK DR
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-6167
Mailing Address - Country:US
Mailing Address - Phone:314-757-1332
Mailing Address - Fax:
Practice Address - Street 1:2055 N HIGH ST STE 230
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-5507
Practice Address - Country:US
Practice Address - Phone:303-200-1131
Practice Address - Fax:303-839-7761
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002023834174400000X
CO60580207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200790301Medicaid
MO931044641Medicare PIN
MOI24594Medicare UPIN