1174553515 NPI number — MR. LAWRENCE P FORMAN III R.D.

Table of content: MR. LAWRENCE P FORMAN III R.D. (NPI 1174553515)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174553515 NPI number — MR. LAWRENCE P FORMAN III R.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORMAN
Provider First Name:
LAWRENCE
Provider Middle Name:
P
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
III
Provider Credential Text:
R.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FORMAN
Provider Other First Name:
LARRY
Provider Other Middle Name:
P
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
R.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1174553515
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 160
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHIPROCK
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87420-0160
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-368-6401
Provider Business Mailing Address Fax Number:
505-368-6431

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
US HIGHWAY 491 NORTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHIPROCK
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87420-0160
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-368-6204
Provider Business Practice Location Address Fax Number:
505-368-6265
Provider Enumeration Date:
07/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  471 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: G2352 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 230062 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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