Provider Demographics
NPI:1346272812
Name:FORSYTHE, KEVIN C (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:C
Last Name:FORSYTHE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1111 LAS TABLAS RD STE R
Mailing Address - Street 2:
Mailing Address - City:TEMPLETON
Mailing Address - State:CA
Mailing Address - Zip Code:93465-9732
Mailing Address - Country:US
Mailing Address - Phone:805-286-4416
Mailing Address - Fax:888-216-9538
Practice Address - Street 1:1111 LAS TABLAS ROAD SUITE R
Practice Address - Street 2:
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-3742
Practice Address - Country:US
Practice Address - Phone:805-286-4416
Practice Address - Fax:888-216-9538
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2022-07-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA96098207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11616353OtherCAQH PROVIDER NUMBER
CAI67917Medicare UPIN
CA11616353OtherCAQH PROVIDER NUMBER