Healthcare Provider Details

I. General information

NPI: 1760489637
Provider Name (Legal Business Name): THOMAS J FOREST M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2005
Last Update Date: 09/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 AMBASSADOR CAFFERY PKWY BUILDING 16
LAFAYETTE LA
70508-6984
US

IV. Provider business mailing address

5000 AMBASSADOR CAFFERY PKWY BUILDING 16
LAFAYETTE LA
70508-6984
US

V. Phone/Fax

Practice location:
  • Phone: 337-406-8009
  • Fax: 337-406-8010
Mailing address:
  • Phone: 337-406-8009
  • Fax: 337-406-8010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number11767R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: