Provider Demographics
NPI:1306966791
Name:LARRY E FORTH O D P C
Entity type:Organization
Organization Name:LARRY E FORTH O D P C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:E
Authorized Official - Last Name:FORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-423-5556
Mailing Address - Street 1:708 S GRANT ST SUITE #18
Mailing Address - Street 2:PO BOX 5209
Mailing Address - City:FITZGERALD
Mailing Address - State:GA
Mailing Address - Zip Code:31750
Mailing Address - Country:US
Mailing Address - Phone:229-423-5556
Mailing Address - Fax:229-423-5179
Practice Address - Street 1:708 S GRANT ST
Practice Address - Street 2:SUITE #18
Practice Address - City:FITZGERALD
Practice Address - State:GA
Practice Address - Zip Code:31750
Practice Address - Country:US
Practice Address - Phone:229-423-5556
Practice Address - Fax:229-423-5179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT000842152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000151819CMedicaid
GA117755OtherEYEMED VISION CARE
GA410027578Medicare PIN
GA55458854SAMedicare PIN
GA117755OtherEYEMED VISION CARE
GA000151819CMedicaid