Provider Demographics
NPI:1740035294
Name:FORMAN, MARIE DIANE (LDO)
Entity type:Individual
Prefix:MS
First Name:MARIE
Middle Name:DIANE
Last Name:FORMAN
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4235 VETERAN DR
Mailing Address - Street 2:
Mailing Address - City:GENESEO
Mailing Address - State:NY
Mailing Address - Zip Code:14454-9442
Mailing Address - Country:US
Mailing Address - Phone:585-243-4004
Mailing Address - Fax:585-243-4009
Practice Address - Street 1:4235 VETERAN DR
Practice Address - Street 2:
Practice Address - City:GENESEO
Practice Address - State:NY
Practice Address - Zip Code:14454-9442
Practice Address - Country:US
Practice Address - Phone:585-243-4004
Practice Address - Fax:585-243-4009
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-18
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY01035-01156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician