Provider Demographics
NPI:1629509302
Name:FORMAN, NATHANIEL HAMILTON (MD)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:HAMILTON
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 1:2615 NE 15TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-1509
Mailing Address - Country:US
Mailing Address - Phone:954-294-2171
Mailing Address - Fax:
Practice Address - Street 1:1005 JOE DIMAGGIO DR
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-5487
Practice Address - Country:US
Practice Address - Phone:954-265-5324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-23
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57.03227208000000X
OH35139206208000000X, 2080P0204X
FLME160857208000000X, 2080P0204X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0456143Medicaid