Provider Demographics
NPI:1295216943
Name:FORSYTHE, SCOTT KENNETH (OD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:KENNETH
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 1:5607 BLACK ONYX DR APT 204
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53718-9161
Mailing Address - Country:US
Mailing Address - Phone:608-963-6793
Mailing Address - Fax:
Practice Address - Street 1:2929 MILTON AVE STE 140
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-0253
Practice Address - Country:US
Practice Address - Phone:072-860-8756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3516-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist