Healthcare Provider Details

I. General information

NPI: 1740272632
Provider Name (Legal Business Name): MARTIN THOMAS FORREST D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 03/19/2020
Certification Date: 03/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 S SANDLAKE CT
MOUNT DORA FL
32757-6084
US

IV. Provider business mailing address

620 S SANDLAKE CT
MOUNT DORA FL
32757-6084
US

V. Phone/Fax

Practice location:
  • Phone: 443-521-5654
  • Fax: 888-727-2212
Mailing address:
  • Phone: 443-521-5654
  • Fax: 888-727-2212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberH0060785
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberDO2292
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: