Provider Demographics
NPI:1629002258
Name:FORMAN, BRUCE DAVID (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:DAVID
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 1:516 E. NIZHONI BLVD.
Mailing Address - Street 2:BOX 1337
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-1337
Mailing Address - Country:US
Mailing Address - Phone:505-722-1000
Mailing Address - Fax:505-726-8557
Practice Address - Street 1:516 E. NIZHONI BLVD.
Practice Address - Street 2:BOX 1337
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-1337
Practice Address - Country:US
Practice Address - Phone:505-722-1000
Practice Address - Fax:505-726-8557
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301044482207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ777344Medicaid
NM16531221Medicaid
NM16531221Medicaid
A76720Medicare UPIN
TX8HBJ25Medicare ID - Type UnspecifiedHSZ001
TX8HBJ26Medicare ID - Type UnspecifiedHSZ002
TX8HBJ27Medicare ID - Type UnspecifiedHSZ003
AZ777344Medicaid
TX8HBW93Medicare ID - Type UnspecifiedHSZ197