Provider Demographics
NPI:1831258912
Name:FORSYTH OPTOMETRIC GROUP,PA
Entity type:Organization
Organization Name:FORSYTH OPTOMETRIC GROUP,PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:FORSYTH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:919-847-0051
Mailing Address - Street 1:101 SAWMILL RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-6148
Mailing Address - Country:US
Mailing Address - Phone:919-847-0051
Mailing Address - Fax:919-846-9003
Practice Address - Street 1:101 SAWMILL RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-6148
Practice Address - Country:US
Practice Address - Phone:919-847-0051
Practice Address - Fax:919-846-9003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1241152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1104911635OtherINDIVIDUAL NPI
NC1164592523OtherINDIVIDUAL NPI
NC1831258912OtherGROUP NPI
NC2348490OtherPTAN
NC1104911635OtherINDIVIDUAL NPI