Provider Demographics
NPI:1992835078
Name:FORMAN, MARVIN (OD)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:
Last Name:FORMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15066 ROSECRANS AVE
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-4740
Mailing Address - Country:US
Mailing Address - Phone:714-739-2020
Mailing Address - Fax:714-739-2202
Practice Address - Street 1:15066 ROSECRANS AVE
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-4740
Practice Address - Country:US
Practice Address - Phone:714-739-2020
Practice Address - Fax:714-739-2202
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5857T152W00000X
WAOD00003857152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0058570Medicaid
CAU78281Medicare UPIN
CASD0058570Medicaid