Healthcare Provider Details

I. General information

NPI: 1265664692
Provider Name (Legal Business Name): KATIE RAE FORMAN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2009
Last Update Date: 07/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 TENBROECK AVE 2ND FLOOR
BRONX NY
10461-2007
US

IV. Provider business mailing address

1601 TENBROECK AVE 2ND FLOOR
BRONX NY
10461-2007
US

V. Phone/Fax

Practice location:
  • Phone: 718-904-4105
  • Fax:
Mailing address:
  • Phone: 718-904-4105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number251142
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberDO034307
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: