Provider Demographics
NPI:1881641793
Name:CANTRELL, FORREST CLARK JR (MD)
Entity Type:Individual
Prefix:MR
First Name:FORREST
Middle Name:CLARK
Last Name:CANTRELL
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:5200 DALLAS HWY
Mailing Address - Street 2:STE 200
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-6318
Mailing Address - Country:US
Mailing Address - Phone:770-943-9150
Mailing Address - Fax:770-212-0276
Practice Address - Street 1:3515 DALLAS HWY
Practice Address - Street 2:STE C
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064
Practice Address - Country:US
Practice Address - Phone:770-943-9150
Practice Address - Fax:770-212-0276
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2023-05-10
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Provider Licenses
StateLicense IDTaxonomies
GA028948208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000382489GMedicaid
GA00382489AMedicaid