Provider Demographics
NPI:1184902314
Name:FORMAN, REBECCA (OD)
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:
Last Name:FORMAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:FORMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:5 BRITTA LN
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-3115
Mailing Address - Country:US
Mailing Address - Phone:845-642-1935
Mailing Address - Fax:
Practice Address - Street 1:5 BRITTA LN
Practice Address - Street 2:
Practice Address - City:NEW CITY
Practice Address - State:NY
Practice Address - Zip Code:10956-3115
Practice Address - Country:US
Practice Address - Phone:845-642-1935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN/A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist