Provider Demographics
NPI:1215042361
Name:FORMAN, EVGENIA (MD)
Entity Type:Individual
Prefix:
First Name:EVGENIA
Middle Name:
Last Name:FORMAN
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 1:2216 DORCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER CENTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-5607
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2216 DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER CENTER
Practice Address - State:MA
Practice Address - Zip Code:02124-5607
Practice Address - Country:US
Practice Address - Phone:617-296-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA228097207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine