Provider Demographics
NPI:1346304540
Name:FORMAN, SETH B (MD)
Entity Type:Individual
Prefix:
First Name:SETH
Middle Name:B
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 1:15416 N FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-1244
Mailing Address - Country:US
Mailing Address - Phone:813-960-4200
Mailing Address - Fax:813-960-2410
Practice Address - Street 1:4915 EHRLICH RD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624-2038
Practice Address - Country:US
Practice Address - Phone:813-960-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96509207ND0900X, 207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0013507OtherCIGNA
FL7110910OtherAETNA
FL592235385OtherUNITED HC
FL93048OtherFL BLUE
FL010196800Medicaid
FL592235385OtherMULTIPLAN
AE538Medicare PIN