Basic Information
| Provider Information | |||||||||
| NPI: | 1366975690 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SCOTT FORMAN, MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 380 ROUTE 202 | ||||||||
| Address2: | |||||||||
| City: | SOMERS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105893222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142775550 | ||||||||
| FaxNumber: | 9142775735 | ||||||||
| Practice Location | |||||||||
| Address1: | 380 ROUTE 202 | ||||||||
| Address2: | |||||||||
| City: | SOMERS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105893222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142775550 | ||||||||
| FaxNumber: | 9142775735 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2017 | ||||||||
| LastUpdateDate: | 04/04/2017 | ||||||||
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| AuthorizedOfficialLastName: | CRUZ | ||||||||
| AuthorizedOfficialFirstName: | VERONICA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9142775550 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SCOTT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 155754-1 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.