Provider Demographics
NPI:1639101777
Name:FORMAN, LISA DIANNE (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DIANNE
Last Name:FORMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:79-01 BROADWAY
Mailing Address - Street 2:H-116
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1329
Mailing Address - Country:US
Mailing Address - Phone:718-334-3044
Mailing Address - Fax:718-334-5759
Practice Address - Street 1:7901 BROADWAY
Practice Address - Street 2:ELMHURST HOSPITAL, ROOM H-116
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1329
Practice Address - Country:US
Practice Address - Phone:718-334-3044
Practice Address - Fax:718-334-5759
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-10-27
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Provider Licenses
StateLicense IDTaxonomies
NY211282208000000X, 2080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine