Provider Demographics
NPI:1962517508
Name:FORG, PATRICIA LYNN (DPM)
Entity type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:LYNN
Last Name:FORG
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3989 32ND ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-2001
Mailing Address - Country:US
Mailing Address - Phone:619-283-2097
Mailing Address - Fax:619-283-2540
Practice Address - Street 1:3989 32ND ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-2001
Practice Address - Country:US
Practice Address - Phone:619-283-2097
Practice Address - Fax:619-283-2540
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3775213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E3775Medicaid
CA000E3775Medicaid
CAE37751Medicare ID - Type Unspecified
CA3605370001Medicare NSC