Provider Demographics
NPI:1528301710
Name:SCOTT K FORMAN M D PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:SCOTT K FORMAN M D PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUDD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-270-0344
Mailing Address - Street 1:360 SAN MIGUEL DR
Mailing Address - Street 2:#701
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7853
Mailing Address - Country:US
Mailing Address - Phone:949-759-3600
Mailing Address - Fax:949-759-9265
Practice Address - Street 1:360 SAN MIGUEL DR
Practice Address - Street 2:#701
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7853
Practice Address - Country:US
Practice Address - Phone:949-759-3600
Practice Address - Fax:949-759-9265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-05
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG71209207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF31830OtherUPIN