Provider Demographics
NPI:1497807531
Name:FORMAN, WALTER H (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:H
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 1:733 US HIGHWAY 1 BLDG 2B
Mailing Address - Street 2:
Mailing Address - City:NORTH PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33408-4513
Mailing Address - Country:US
Mailing Address - Phone:561-841-8588
Mailing Address - Fax:561-841-8533
Practice Address - Street 1:733 US HIGHWAY 1 BLDG 2B
Practice Address - Street 2:
Practice Address - City:NORTH PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33408-4513
Practice Address - Country:US
Practice Address - Phone:561-841-8588
Practice Address - Fax:561-841-8533
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME179282085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLN272625OtherWELLCARE
FL50884OtherBLUE CROSS BLUE SHIELD
FLN272625OtherSOUTH FLORIDA REGION
FL054676300Medicaid
FLN272625OtherHEALTHEASE
FL990105OtherNEIGHBORHOOD HEALTH
FLN272625OtherSTAYWELL
FL300060057OtherRAILROAD MEDICARE
FL300060057OtherRAILROAD MEDICARE
FLN272625OtherSOUTH FLORIDA REGION