Provider Demographics
NPI:1376641712
Name:DR JAMES FORRESTAL INC
Entity Type:Organization
Organization Name:DR JAMES FORRESTAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:FORRESTAL INC
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:580-226-5120
Mailing Address - Street 1:830 16TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1818
Mailing Address - Country:US
Mailing Address - Phone:580-226-5120
Mailing Address - Fax:580-223-1003
Practice Address - Street 1:830 16TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1818
Practice Address - Country:US
Practice Address - Phone:580-226-5120
Practice Address - Fax:580-223-1003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2309207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========OtherTAX ID #
OKE09677Medicare UPIN