Provider Demographics
NPI:1295795664
Name:FORREST, NATHAN BENJAMIN (DO)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:BENJAMIN
Last Name:FORREST
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4777 US HIGHWAY 259
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-7668
Mailing Address - Country:US
Mailing Address - Phone:903-663-7393
Mailing Address - Fax:903-663-7394
Practice Address - Street 1:6901 MEDICAL PKWY
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-7910
Practice Address - Country:US
Practice Address - Phone:254-751-4000
Practice Address - Fax:903-663-7394
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK35762085R0202X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00195387OtherRR/MEDICARE
8W7435OtherBLUE CROSS BLUE SHIELD
TX1046328-05Medicaid
TX1046328-04OtherCSHCN
TX8P1488OtherBLUE SHIELD
TXP00195387OtherRR/MEDICARE
TX1046328-05Medicaid
TX8J3931Medicare PIN
TXG82113Medicare UPIN