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NPI Code Detail

MEDICARE: DR. IVIS THEODORE FORRESTER PH.D., RD

MEDICARE: DR. IVIS THEODORE FORRESTER PH.D., RD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1133V00000XRegistered DietitianD02016MD
2133VN1006XMetabolic Nutrition Registered DietitianD02016MD

General Provider Information

NPI Number : 1437438645
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. IVIS THEODORE FORRESTER PH.D., RD
Provider Business Mailing Address
First Line : 6210 GLEN FALLS RD
Second Line :
City : REISTERSTOWN
State : MD
Zip : 21136
Country : US
Telephone Number : 410-833-3682
Fax Number : 410-833-3682
Provider Business Practice Location Address
First Line : 3939 REISTERSTOWN RD
Second Line :
City : BALTIMORE
State : MD
Zip : 21251
Country : US
Telephone Number : 410-367-7821
Fax Number : 410-367-7823
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/05/2011
Last Update Date : 08/05/2011

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