Provider Demographics
NPI:1144398942
Name:FORMAN, SCOTT (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:FORMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELCHERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:01007-9433
Mailing Address - Country:US
Mailing Address - Phone:413-313-1196
Mailing Address - Fax:413-313-1186
Practice Address - Street 1:142 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BELCHERTOWN
Practice Address - State:MA
Practice Address - Zip Code:01007-9433
Practice Address - Country:US
Practice Address - Phone:413-323-1196
Practice Address - Fax:413-323-1186
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2025-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA49612207WX0109X
NY155754207WX0109X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0109XAllopathic & Osteopathic PhysiciansOphthalmologyNeuro-ophthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01005930Medicaid
NY58D601Medicare PIN
NY01005930Medicaid