Provider Demographics
NPI:1245493840
Name:FREDLINE, FORREST R (DO)
Entity type:Individual
Prefix:DR
First Name:FORREST
Middle Name:R
Last Name:FREDLINE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-302-2700
Mailing Address - Fax:208-302-2725
Practice Address - Street 1:4400 E FLAMINGO AVE STE 200
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687
Practice Address - Country:US
Practice Address - Phone:208-302-2700
Practice Address - Fax:208-302-2725
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101017665208600000X
IDO-0712208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery