Provider Demographics
NPI:1073516308
Name:FORMOSA, PAULA JEAN (MD)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:JEAN
Last Name:FORMOSA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 N SIOUX POINT RD
Mailing Address - Street 2:
Mailing Address - City:DAKOTA DUNES
Mailing Address - State:SD
Mailing Address - Zip Code:57049-5312
Mailing Address - Country:US
Mailing Address - Phone:605-217-2667
Mailing Address - Fax:605-217-2900
Practice Address - Street 1:575 N SIOUX POINT RD
Practice Address - Street 2:
Practice Address - City:DAKOTA DUNES
Practice Address - State:SD
Practice Address - Zip Code:57049-5312
Practice Address - Country:US
Practice Address - Phone:605-217-2667
Practice Address - Fax:605-217-2900
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5141208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
E49798Medicare UPIN
SD41004Medicare ID - Type Unspecified
SD1295480001Medicare NSC
IAI8285Medicare ID - Type Unspecified