Provider Demographics
NPI:1134188386
Name:FORSYTHE, JOHN THOMAS (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:THOMAS
Last Name:FORSYTHE
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 4825
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4825
Mailing Address - Country:US
Mailing Address - Phone:360-882-2778
Mailing Address - Fax:
Practice Address - Street 1:19250 SW 65TH AVE
Practice Address - Street 2:#110
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062
Practice Address - Country:US
Practice Address - Phone:503-692-1205
Practice Address - Fax:503-692-1207
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD13146207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR267732Medicaid
OR107152Medicare ID - Type Unspecified
OR267732Medicaid