Provider Demographics
NPI:1871606004
Name:FORMAN, PAUL (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:FORMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:950 E BOGARD RD STE 233
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7185
Mailing Address - Country:US
Mailing Address - Phone:907-376-2273
Mailing Address - Fax:907-733-1735
Practice Address - Street 1:34300 TALKEETNA S SPUR RD
Practice Address - Street 2:
Practice Address - City:TALKEETNA
Practice Address - State:AK
Practice Address - Zip Code:99676
Practice Address - Country:US
Practice Address - Phone:907-733-2273
Practice Address - Fax:907-733-1735
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AK3728207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD44651Medicaid
AKP00115873OtherRAILROAD MEDICARE PIN#
AK152618Medicare PIN
AKMD44651Medicaid