1528301710 NPI number — SCOTT K. FORMAN M.D. PROFESSIONAL CORPORATION

Table of content: (NPI 1528301710)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528301710 NPI number — SCOTT K. FORMAN M.D. PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SCOTT K. FORMAN M.D. PROFESSIONAL CORPORATION
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:
1528301710
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
360 SAN MIGUEL DR
Provider Second Line Business Mailing Address:
#701
Provider Business Mailing Address City Name:
NEWPORT BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92660-7853
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-759-3600
Provider Business Mailing Address Fax Number:
949-759-9265

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
360 SAN MIGUEL DR
Provider Second Line Business Practice Location Address:
#701
Provider Business Practice Location Address City Name:
NEWPORT BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92660-7853
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-759-3600
Provider Business Practice Location Address Fax Number:
949-759-9265
Provider Enumeration Date:
04/05/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BUDD
Authorized Official First Name:
MELINDA
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
949-270-0344

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  G71209 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: F31830 . This is a "UPIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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