Provider Demographics
NPI:1225008170
Name:FORYSTEK, BRUCE E (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:E
Last Name:FORYSTEK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BUILDING 0221
Mailing Address - Street 2:
Mailing Address - City:CEDAR FALLS
Mailing Address - State:IA
Mailing Address - Zip Code:50614-0221
Mailing Address - Country:US
Mailing Address - Phone:319-273-2009
Mailing Address - Fax:319-273-7030
Practice Address - Street 1:BUILDING 0221
Practice Address - Street 2:
Practice Address - City:CEDAR FALLS
Practice Address - State:IA
Practice Address - Zip Code:50614-0221
Practice Address - Country:US
Practice Address - Phone:319-273-2009
Practice Address - Fax:319-273-7030
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA23122390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0197566Medicaid
IAE54118Medicare UPIN