Provider Demographics
NPI:1497836795
Name:DE FORREST, MICHAEL JUDE (DC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JUDE
Last Name:DE FORREST
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 N FULTON ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021
Mailing Address - Country:US
Mailing Address - Phone:315-253-2962
Mailing Address - Fax:315-258-0017
Practice Address - Street 1:105 N FULTON ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021
Practice Address - Country:US
Practice Address - Phone:315-253-2962
Practice Address - Fax:315-258-0017
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX0020751111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY224464OtherWORKERS COMP
T26474Medicare UPIN
NY37009BMedicare ID - Type Unspecified