Provider Demographics
NPI:1528067998
Name:FORKOWITZ, MANNY JOSEPH (MD)
Entity type:Individual
Prefix:DR
First Name:MANNY
Middle Name:JOSEPH
Last Name:FORKOWITZ
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 1:3000 BROWN ST
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-5330
Mailing Address - Country:US
Mailing Address - Phone:972-937-4266
Mailing Address - Fax:
Practice Address - Street 1:3000 BROWN ST
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-5330
Practice Address - Country:US
Practice Address - Phone:972-937-4266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG0406208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0143410001Medicare NSC
B22753Medicare UPIN
TXGJ06Medicare ID - Type Unspecified