Individual
JACK L FOREST
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.O.
Contact information
Practice address
2016 S MAIN ST, MARYVILLE, MO 64468-2655
(660) 562-2600
(660) 562-7911
Mailing address
114 E SOUTH HILLS DR, MARYVILLE, MO 64468-2659
(660) 562-2600
(660) 562-7911
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
049972
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
7313519
—
VA
01
—
C06695
GROUP PTAN
VA
01
—
C09633
GROUP PTAN
VA
Enumeration date
10/04/2005
Last updated
01/06/2017
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