Basic Information
Provider Information | |||||||||
NPI: | 1346304540 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FORMAN | ||||||||
FirstName: | SETH | ||||||||
MiddleName: | B | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 15416 N FLORIDA AVE | ||||||||
Address2: |   | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336131244 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8139604200 | ||||||||
FaxNumber: | 8139602410 | ||||||||
Practice Location | |||||||||
Address1: | 4915 EHRLICH RD | ||||||||
Address2: |   | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336242038 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8139602400 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/21/2006 | ||||||||
LastUpdateDate: | 09/12/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0900X | ME96509 | FL | N |   | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207NS0135X | ME96509 | FL | N |   | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology | 207N00000X | ME96509 | FL | Y |   | Allopathic & Osteopathic Physicians | Dermatology |   |
ID Information
ID | Type | State | Issuer | Description | 0013507 | 01 | FL | CIGNA | OTHER | 7110910 | 01 | FL | AETNA | OTHER | 592235385 | 01 | FL | UNITED HC | OTHER | 93048 | 01 | FL | FL BLUE | OTHER | 010196800 | 05 | FL |   | MEDICAID | 592235385 | 01 | FL | MULTIPLAN | OTHER |