Provider Demographics
NPI:1144230392
Name:FORZLEY, SAMUEL JOSEPH (OD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:JOSEPH
Last Name:FORZLEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1192 WALTER ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:LEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60439-2903
Mailing Address - Country:US
Mailing Address - Phone:630-269-8518
Mailing Address - Fax:
Practice Address - Street 1:1192 WALTER ST
Practice Address - Street 2:SUITE A
Practice Address - City:LEMONT
Practice Address - State:IL
Practice Address - Zip Code:60439-2903
Practice Address - Country:US
Practice Address - Phone:630-269-8518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008265152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0001621942OtherBLUE CROSS BLUE SHIELD IL
K31416OtherMEDICARE
IL046-008265Medicaid
K31416OtherMEDICARE
IL046-008265Medicaid
0001621942OtherBLUE CROSS BLUE SHIELD IL