Provider Demographics
NPI:1699507954
Name:FORMAN, NATHAN ABRAHAM (OD)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:ABRAHAM
Last Name:FORMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 WINDSOR LN
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92831-2224
Mailing Address - Country:US
Mailing Address - Phone:562-370-0320
Mailing Address - Fax:
Practice Address - Street 1:1508 WINDSOR LN
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-2224
Practice Address - Country:US
Practice Address - Phone:562-370-0320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-15
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35813152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist