Provider Demographics
NPI:1235285644
Name:FORMAN, CHRISTOPHER W (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:W
Last Name:FORMAN
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:PO BOX 4540
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89702-4540
Mailing Address - Country:US
Mailing Address - Phone:775-882-0430
Mailing Address - Fax:775-852-6902
Practice Address - Street 1:2874 N CARSON ST
Practice Address - Street 2:SUITE 200
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89706-0251
Practice Address - Country:US
Practice Address - Phone:775-445-7170
Practice Address - Fax:775-883-0959
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5528207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002013125Medicaid
NV110224130OtherRAILROAD MEDICARE PROV
NVNV0117OtherBCBS PROVIDER #
NV002013125Medicaid
NVD95259Medicare UPIN