Basic Information
| Provider Information | |||||||||
| NPI: | 1629002258 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORMAN | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 516 E. NIZHONI BLVD. | ||||||||
| Address2: | BOX 1337 | ||||||||
| City: | GALLUP | ||||||||
| State: | NM | ||||||||
| PostalCode: | 873011337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057221000 | ||||||||
| FaxNumber: | 5057268557 | ||||||||
| Practice Location | |||||||||
| Address1: | 516 E. NIZHONI BLVD. | ||||||||
| Address2: | BOX 1337 | ||||||||
| City: | GALLUP | ||||||||
| State: | NM | ||||||||
| PostalCode: | 873011337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057221000 | ||||||||
| FaxNumber: | 5057268557 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 10/31/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301044482 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 777344 | 05 | AZ | MEDICAID | 16531221 | 05 | NM | MEDICAID |