Provider Demographics
NPI:1649258351
Name:FORRISTALL, RONALD MARK (MD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:MARK
Last Name:FORRISTALL
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 1:601 E 13TH ST
Mailing Address - Street 2:SUITE G
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-2962
Mailing Address - Country:US
Mailing Address - Phone:918-786-3391
Mailing Address - Fax:918-786-7264
Practice Address - Street 1:601 E 13TH ST
Practice Address - Street 2:SUITE G
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-2962
Practice Address - Country:US
Practice Address - Phone:918-786-3391
Practice Address - Fax:918-786-7264
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK16738207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
E08019Medicare UPIN
4513920001Medicare NSC