Provider Demographics
NPI:1447216270
Name:FORESTIERE, LEE A (M D)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:A
Last Name:FORESTIERE
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 W 40TH AVE
Mailing Address - Street 2:STE 403
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-6329
Mailing Address - Country:US
Mailing Address - Phone:870-534-4188
Mailing Address - Fax:870-534-7964
Practice Address - Street 1:1609 W 40TH AVE
Practice Address - Street 2:STE 403
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-6329
Practice Address - Country:US
Practice Address - Phone:870-534-4188
Practice Address - Fax:870-534-7964
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4813174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR103036001Medicaid
ARB90202Medicare UPIN
AR51747Medicare PIN