1407040710 NPI number — JONATHAN D FORMAN MD PA

Table of content: (NPI 1407040710)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407040710 NPI number — JONATHAN D FORMAN MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JONATHAN D FORMAN MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407040710
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4606 S MATANZAS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33611-2748
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-890-8004
Provider Business Mailing Address Fax Number:
813-290-9691

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2605 W SWANN AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33609-4039
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-890-8004
Provider Business Practice Location Address Fax Number:
813-290-9691
Provider Enumeration Date:
08/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FORMAN
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
813-890-8004

Provider Taxonomy Codes

  • Taxonomy code: 207YX0905X , with the licence number:  ME95483 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 275769900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 016535300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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