Provider Demographics
NPI:1376509067
Name:FORSYTHE, STEPHEN M (DO)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:M
Last Name:FORSYTHE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 N STATE ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:DESLOGE
Mailing Address - State:MO
Mailing Address - Zip Code:63601-3052
Mailing Address - Country:US
Mailing Address - Phone:573-431-2829
Mailing Address - Fax:573-431-7186
Practice Address - Street 1:330 N STATE ST
Practice Address - Street 2:SUITE C
Practice Address - City:DESLOGE
Practice Address - State:MO
Practice Address - Zip Code:63601-3052
Practice Address - Country:US
Practice Address - Phone:573-431-2829
Practice Address - Fax:573-431-7186
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR9567207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO240928614Medicaid
MO000011753Medicare PIN
D41474Medicare UPIN