1871695460 NPI number — DR. DENNIS STEVEN FORMAN O.D.

Table of content: DR. DENNIS STEVEN FORMAN O.D. (NPI 1871695460)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871695460 NPI number — DR. DENNIS STEVEN FORMAN O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORMAN
Provider First Name:
DENNIS
Provider Middle Name:
STEVEN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

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:
1871695460
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1500 DIAMOND HILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOONSOCKET
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02895-1547
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-769-3310
Provider Business Mailing Address Fax Number:
401-769-4147

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
481 CLINTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOONSOCKET
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02895-3214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-769-3310
Provider Business Practice Location Address Fax Number:
401-769-4147
Provider Enumeration Date:
09/02/2006

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: 152W00000X , with the licence number:  ODT00339 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3236942/7082094PIN . This is a "AETNA" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 203181 . This is a "BLUE CHIP" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 9855-7 . This is a "BLUE SHIELD BLUE CROSS" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 27568/10350 . This is a "NEIGHBORHOOD HEALTH PLAN" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 131028/168605 . This is a "COLE VISION" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 2200924 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 9009855 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".




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