Healthcare Provider Details

I. General information

NPI: 1265727309
Provider Name (Legal Business Name): KEVIN FORSYTHE MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 LAS TABLAS ROAD SUITE R
TEMPLETON CA
93465-3742
US

IV. Provider business mailing address

1111 LAS TABLAS ROAD SUITE R
TEMPLETON CA
93465-3742
US

V. Phone/Fax

Practice location:
  • Phone: 805-286-4416
  • Fax: 888-216-9538
Mailing address:
  • Phone: 805-286-4416
  • Fax: 888-216-9538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberA96098
License Number StateCA

VIII. Authorized Official

Name: KEVIN C FORSYTHE
Title or Position: PRESIDENT
Credential: MD
Phone: 805-952-5723