Provider Demographics
NPI:1285611160
Name:FORRESTAL, JAMES (DO)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:
Last Name:FORRESTAL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 16TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1818
Mailing Address - Country:US
Mailing Address - Phone:580-226-5120
Mailing Address - Fax:580-223-1003
Practice Address - Street 1:830 16TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1818
Practice Address - Country:US
Practice Address - Phone:580-226-5120
Practice Address - Fax:580-223-1003
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-30
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2309207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100117700Medicaid
OK100117700Medicaid