Provider Demographics
NPI:1962639831
Name:FOREMAN, REBECCA SUZANNE (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:SUZANNE
Last Name:FOREMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:SUZANNE
Other - Last Name:HOODECHECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1115 SE 164TH AVE
Mailing Address - Street 2:DEPT. 358
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9324
Mailing Address - Country:US
Mailing Address - Phone:360-729-1462
Mailing Address - Fax:360-729-3104
Practice Address - Street 1:1615 DELAWARE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2367
Practice Address - Country:US
Practice Address - Phone:360-501-3547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-17
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010014001207N00000X
IL125.056329207R00000X
WAMD60356693207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500656692Medicaid
WA2029200Medicaid
OR500656692Medicaid