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General NPI Number Information
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NPI Number | 1629509302
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Entity Type | Individual
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Provider Name | NATHANIEL HAMILTON FORMAN M.D.
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Gender | Male
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Dates
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Enumeration Date | 03/23/2017
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Last Update Date | 06/29/2023
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Provider Practice Location Address
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Address Line | 1005 JOE DIMAGGIO DR
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City | HOLLYWOOD
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State | FL
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Zip | 33021-5487
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Country | US
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Telephone | 954-265-5324
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Fax |
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Provider Business Mailing Address
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Address Line | 2615 NE 15TH ST
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City | FORT LAUDERDALE
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State | FL
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Zip | 33304-1509
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Country | US
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Telephone | 954-294-2171
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 57.03227
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 35139206
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License Number State | OH
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Taxonomy #3
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | ME160857
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License Number State | FL
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Taxonomy #4
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Taxonomy Code | 2080P0204X
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Taxonomy Name | Pediatric Emergency Medicine (Pediatrics) Physician
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License Number | 35139206
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License Number State | OH
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Taxonomy #5
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 2080P0204X
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Taxonomy Name | Pediatric Emergency Medicine (Pediatrics) Physician
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License Number | ME160857
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License Number State | FL
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