Healthcare Provider Details

I. General information

NPI: 1750372694
Provider Name (Legal Business Name): ISADORE P FORMAN DPM LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 01/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E LANCASTER AVE STE 117
WYNNEWOOD PA
19096-3450
US

IV. Provider business mailing address

100 E LANCASTER AVE STE 117
WYNNEWOOD PA
19096-3450
US

V. Phone/Fax

Practice location:
  • Phone: 610-649-9662
  • Fax:
Mailing address:
  • Phone: 610-649-9662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberSL002073L
License Number StatePA

VIII. Authorized Official

Name: WILLIAM R FORMAN
Title or Position: PRESIDENT
Credential: DPM
Phone: 610-649-9662