Healthcare Provider Details

I. General information

NPI: 1316065725
Provider Name (Legal Business Name): LARRY E. FORTH O.D.P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 DOCTORS DRIVE SUITE 105
DOUGLAS GA
31533
US

IV. Provider business mailing address

POST OFFICE BOX 2740
DOUGLAS GA
31534
US

V. Phone/Fax

Practice location:
  • Phone: 912-384-1840
  • Fax: 912-384-5976
Mailing address:
  • Phone: 912-384-1840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number842T
License Number StateGA

VIII. Authorized Official

Name: DR. LARRY E FORTH
Title or Position: OPTOMETRIST
Credential:
Phone: 912-384-1840