Provider Demographics
NPI:1649382995
Name:FORREST, THEODORE (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:FORREST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 36218
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40233-6218
Mailing Address - Country:US
Mailing Address - Phone:502-634-6767
Mailing Address - Fax:502-634-6775
Practice Address - Street 1:1 AUDUBON PLAZA DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1318
Practice Address - Country:US
Practice Address - Phone:502-634-6767
Practice Address - Fax:502-634-6775
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY23633207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1050434OtherPASSPORT
IN200351080Medicaid
KY2432855000OtherPASSPORT ADVANTAGE
KY64236334Medicaid
KY000000048673OtherANTHEM
KY64236334Medicaid
KY000000048673OtherANTHEM
KY0097103Medicare PIN