Provider Demographics
NPI:1174553515
Name:FORMAN, LAWRENCE P III (RD)
Entity type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:P
Last Name:FORMAN
Suffix:III
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:LARRY
Other - Middle Name:P
Other - Last Name:FORMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RD
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:SHIPROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87420-0160
Mailing Address - Country:US
Mailing Address - Phone:505-368-6401
Mailing Address - Fax:505-368-6431
Practice Address - Street 1:US HIGHWAY 491 NORTH
Practice Address - Street 2:
Practice Address - City:SHIPROCK
Practice Address - State:NM
Practice Address - Zip Code:87420-0160
Practice Address - Country:US
Practice Address - Phone:505-368-6204
Practice Address - Fax:505-368-6265
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM471133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMG2352Medicaid
AZ230062Medicaid
AZ230062Medicaid
NMG2352Medicaid
NM8HBN87Medicare ID - Type Unspecified