Provider Demographics
NPI:1205865193
Name:RITLAND, FORREST R (MD)
Entity Type:Individual
Prefix:
First Name:FORREST
Middle Name:R
Last Name:RITLAND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:1600 W UNIVERSITY AVE STE 215
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3115
Mailing Address - Country:US
Mailing Address - Phone:928-774-1693
Mailing Address - Fax:928-774-3533
Practice Address - Street 1:1200 N BEAVER STREET
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001
Practice Address - Country:US
Practice Address - Phone:928-773-2489
Practice Address - Fax:928-773-2283
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-02
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ16350207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ274671Medicaid
AZAZ0255820OtherBLUE CROSS BLUE SHIELD
E76258Medicare UPIN
MD16350Medicare ID - Type Unspecified