Healthcare Provider Details

I. General information

NPI: 1962517508
Provider Name (Legal Business Name): PATRICIA LYNN FORG DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 06/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3989 32ND ST
SAN DIEGO CA
92104-2001
US

IV. Provider business mailing address

3989 32ND ST
SAN DIEGO CA
92104-2001
US

V. Phone/Fax

Practice location:
  • Phone: 619-283-2097
  • Fax: 619-283-2540
Mailing address:
  • Phone: 619-283-2097
  • Fax: 619-283-2540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE3775
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: