Provider Demographics
NPI:1982844098
Name:FORSTALL, PETER GEORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:GEORGE
Last Name:FORSTALL
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:PO BOX 741729
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-1729
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:425 E 5350 S STE 400
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6932
Practice Address - Country:US
Practice Address - Phone:801-476-0184
Practice Address - Fax:801-479-5642
Is Sole Proprietor?:No
Enumeration Date:2009-03-02
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5416513-1205207RC0000X, 207RC0001X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
1477643179OtherGROUP NPI
UT000068347Medicare PIN