Provider Demographics
NPI:1710120498
Name:FORMAN, KATHERINE C (MD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:C
Last Name:FORMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 W SAN MATEO RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4746
Mailing Address - Country:US
Mailing Address - Phone:505-660-5794
Mailing Address - Fax:
Practice Address - Street 1:2801 DAGGETT AVE
Practice Address - Street 2:OHSU
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1106
Practice Address - Country:US
Practice Address - Phone:541-274-4210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-10
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program