Provider Demographics
NPI:1639365158
Name:MICHAEL W FORMISANO MD PA
Entity Type:Organization
Organization Name:MICHAEL W FORMISANO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:FORMISANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD PA
Authorized Official - Phone:954-989-4110
Mailing Address - Street 1:3939 HOLLYWOOD BLVD
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-6749
Mailing Address - Country:US
Mailing Address - Phone:954-989-4110
Mailing Address - Fax:954-989-7855
Practice Address - Street 1:4024 N CIRCLE DR
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-6726
Practice Address - Country:US
Practice Address - Phone:954-989-4110
Practice Address - Fax:954-989-7855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-18
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 91614208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME 91614OtherME LICENSE