Provider Demographics
NPI:1003887589
Name:FORNEY, JOSEPH WAYNE SR (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:WAYNE
Last Name:FORNEY
Suffix:SR
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 1:7 SHACKLEFORD WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-3886
Mailing Address - Country:US
Mailing Address - Phone:501-614-3606
Mailing Address - Fax:501-663-5017
Practice Address - Street 1:7 SHACKLEFORD WEST BLVD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-3886
Practice Address - Country:US
Practice Address - Phone:501-614-3606
Practice Address - Fax:501-663-5017
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20770207RC0000X
ARE-6499207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ123711Medicaid
AZCH003OtherTRICARE
AZ00882OtherRR MEDICARE
AZAZ0747910OtherBCBS ID
AZ200691531OtherTAX ID
AZAZ0747910OtherBCBS ID
AZ200691531OtherTAX ID
AZZ78696Medicare ID - Type UnspecifiedINDIVIDUAL