Provider Demographics
NPI:1881620763
Name:FORRESTER, GRANT LEROY (MD)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:LEROY
Last Name:FORRESTER
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 1:2088 HAWTHORNE DR
Mailing Address - Street 2:
Mailing Address - City:PELLA
Mailing Address - State:IA
Mailing Address - Zip Code:50219-7914
Mailing Address - Country:US
Mailing Address - Phone:785-313-5694
Mailing Address - Fax:785-565-4754
Practice Address - Street 1:601 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MAQUOKETA
Practice Address - State:IA
Practice Address - Zip Code:52060-1201
Practice Address - Country:US
Practice Address - Phone:563-652-2474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA30745207P00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100644460FMedicaid
KS068002319OtherMEDICARE PTAN
LA1129879Medicaid