Provider Demographics
NPI:1508073511
Name:JELLISON, FORREST C (MD)
Entity Type:Individual
Prefix:MR
First Name:FORREST
Middle Name:C
Last Name:JELLISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:11370 ANDERSON ST STE 1100
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3450
Mailing Address - Country:US
Mailing Address - Phone:909-558-4196
Mailing Address - Fax:909-558-4806
Practice Address - Street 1:11370 ANDERSON ST STE 1100
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354
Practice Address - Country:US
Practice Address - Phone:909-558-4196
Practice Address - Fax:909-558-4806
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA98781208800000X, 207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive Surgery
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEZ222ZMedicare PIN