| Doctor Name: | EVERETT ROY FORMAN |
| NPI Number: | 1528061967 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | M.D. |
| License Number: | 103928-1 |
| Business Practice Address: | 585 Troy Schenectady Rd Latham, NY - 121102811 |
| Business Phone Number: | 5187856004 |
| Business Fax Number: | 5187851702 |
| Mailing Address: | 47 Sweet Rd, BALLSTON LAKE |
| State: | NY |
| Postal Code: | 120191805 |
| Phone Number: | 5187856004 |
| Fax Number: | 5187851702 |
| NPI Enumeration Date: | 05/31/2005 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | 103928-1 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NY |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |