Basic Information
| Provider Information | |||||||||
| NPI: | 1649233917 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORMAN | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7068 | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 237070068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7576863508 | ||||||||
| FaxNumber: | 7576860541 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 MEADE PARKWAY | ||||||||
| Address2: | |||||||||
| City: | SUFFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234344259 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575390251 | ||||||||
| FaxNumber: | 7575396237 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2006 | ||||||||
| LastUpdateDate: | 03/05/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 0101052413 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 0101052413 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 7905005 | 05 | NC | MEDICAID | 6040748 | 05 | VA | MEDICAID | 290007366 | 01 | VA | RAILROAD MEDICARE | OTHER | 02136354 | 05 | NY | MEDICAID |