Provider Demographics
NPI:1902877707
Name:FORNOFF, ROBERT ADAM (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ADAM
Last Name:FORNOFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 BEAVER AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50310-3903
Mailing Address - Country:US
Mailing Address - Phone:515-255-3181
Mailing Address - Fax:515-255-9392
Practice Address - Street 1:2301 BEAVER AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310-3903
Practice Address - Country:US
Practice Address - Phone:515-255-3181
Practice Address - Fax:515-255-9392
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA35011208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA20764OtherBCBS-EAST
IA20794OtherBCBS-WEST
IA0431916Medicaid