Provider Demographics
NPI:1760434435
Name:FORSYTHE, KENNETH G (OD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:G
Last Name:FORSYTHE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN DELLS
Mailing Address - State:WI
Mailing Address - Zip Code:53965-1358
Mailing Address - Country:US
Mailing Address - Phone:608-254-8383
Mailing Address - Fax:608-253-6223
Practice Address - Street 1:1302 BROADWAY
Practice Address - Street 2:
Practice Address - City:WISCONSIN DELLS
Practice Address - State:WI
Practice Address - Zip Code:53965-1358
Practice Address - Country:US
Practice Address - Phone:608-254-8383
Practice Address - Fax:608-253-6223
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1318-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1006698OtherPHYSICIANS PLUS
WI60090OtherDEAN HEALTH INSURANCE
WI38573400Medicaid
WI38573400Medicaid
WI1006698OtherPHYSICIANS PLUS
WI000347810Medicare PIN