Provider Demographics
NPI:1366975690
Name:SCOTT FORMAN, MD PC
Entity type:Organization
Organization Name:SCOTT FORMAN, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-277-5550
Mailing Address - Street 1:380 ROUTE 202
Mailing Address - Street 2:
Mailing Address - City:SOMERS
Mailing Address - State:NY
Mailing Address - Zip Code:10589-3222
Mailing Address - Country:US
Mailing Address - Phone:914-277-5550
Mailing Address - Fax:914-277-5735
Practice Address - Street 1:380 ROUTE 202
Practice Address - Street 2:
Practice Address - City:SOMERS
Practice Address - State:NY
Practice Address - Zip Code:10589-3222
Practice Address - Country:US
Practice Address - Phone:914-277-5550
Practice Address - Fax:914-277-5735
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SCOTT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-04-04
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY155754-1207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
58D601Medicare UPIN