Healthcare Provider Details

I. General information

NPI: 1144398942
Provider Name (Legal Business Name): SCOTT FORMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 10/17/2025
Certification Date: 10/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 N MAIN ST
BELCHERTOWN MA
01007-9433
US

IV. Provider business mailing address

142 N MAIN ST
BELCHERTOWN MA
01007-9433
US

V. Phone/Fax

Practice location:
  • Phone: 413-323-1196
  • Fax: 413-323-1186
Mailing address:
  • Phone: 413-313-1196
  • Fax: 413-313-1186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0109X
TaxonomyNeuro-ophthalmology Physician
License Number49612
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207WX0109X
TaxonomyNeuro-ophthalmology Physician
License Number155754
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: