Provider Demographics
NPI:1730378902
Name:DR. TODD FORMAN, INC.
Entity type:Organization
Organization Name:DR. TODD FORMAN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:A
Authorized Official - Last Name:FORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-646-7733
Mailing Address - Street 1:351 HOSPITAL RD
Mailing Address - Street 2:SUITE 406
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3509
Mailing Address - Country:US
Mailing Address - Phone:949-646-7733
Mailing Address - Fax:949-646-6155
Practice Address - Street 1:351 HOSPITAL RD
Practice Address - Street 2:SUITE 406
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3509
Practice Address - Country:US
Practice Address - Phone:949-646-7733
Practice Address - Fax:949-646-6155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67377261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19461Medicare PIN
CAH29292Medicare UPIN