Provider Demographics
NPI:1528061967
Name:FORMAN, EVERETT ROY (MD)
Entity type:Individual
Prefix:
First Name:EVERETT
Middle Name:ROY
Last Name:FORMAN
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 1:47 SWEET RD
Mailing Address - Street 2:
Mailing Address - City:BALLSTON LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12019-1805
Mailing Address - Country:US
Mailing Address - Phone:518-785-6004
Mailing Address - Fax:518-785-1702
Practice Address - Street 1:585 TROY SCHENECTADY RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-2811
Practice Address - Country:US
Practice Address - Phone:518-785-6004
Practice Address - Fax:518-785-1702
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103928-1208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
10000672OtherCDPHP
01148OtherMVP
000401336001OtherBLUE SHIELD OF NENY
49E991OtherEMPIRE BCBS
01148OtherMVP
49E991OtherEMPIRE BCBS