Healthcare Provider Details

I. General information

NPI: 1679711691
Provider Name (Legal Business Name): DOUGLAS ALLEN FORSYTH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2009
Last Update Date: 07/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34101 FARENHOLT AVE
SAN DIEGO CA
92134-7000
US

IV. Provider business mailing address

34101 FARENHOLT AVE
SAN DIEGO CA
92134-7000
US

V. Phone/Fax

Practice location:
  • Phone: 760-830-5631
  • Fax: 619-532-5156
Mailing address:
  • Phone: 760-830-5631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: