Provider Demographics
NPI:1336142736
Name:HASLUP, FORREST C (MD)
Entity Type:Individual
Prefix:DR
First Name:FORREST
Middle Name:C
Last Name:HASLUP
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:PO BOX 10744
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33757-8744
Mailing Address - Country:US
Mailing Address - Phone:727-532-0002
Mailing Address - Fax:727-266-4928
Practice Address - Street 1:4211 VANDYKE ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558-8004
Practice Address - Country:US
Practice Address - Phone:813-264-6490
Practice Address - Fax:813-321-1878
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME40892208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0472972 00Medicaid
FLB23335Medicare UPIN
FL0472972 00Medicaid
FL07872YMedicare PIN