Active NPI
Mark D Forman, PHD
- Psychologist
- San Jose, CA
National Provider Identifier
1427354414
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Psychologist
- License
- PSY23310
- Practice address
- 1769 Park Ave
Suite 110
San Jose, CA 95126-2029 - Phone
- (408) 841-7443
- NPI assigned
- Feb 8, 2011
- Last updated
- Feb 8, 2011
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychologist | 103T00000X | PSY23310 | CA | Primary |
Addresses
Primary practice location
1769 Park Ave
Suite 110
San Jose, CA 95126-2029
Mailing address
1769 Park Ave
Suite 110
San Jose, CA 95126-2029
Phone (408) 841-7443
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: No
- Medical equipment: Yes
- Home health: No
- Power mobility devices: No
- Hospice: No
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 23310 | CA | MD | Addiction (Substance Use Disorder) Counselor |
| PSY23310 | CA | MD | Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1297123200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1297123200000",
"number": "1427354414",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1769 PARK AVE",
"address_2": "SUITE 110",
"city": "SAN JOSE",
"state": "CA",
"postal_code": "951262029",
"telephone_number": "408-841-7443"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1769 PARK AVE",
"address_2": "SUITE 110",
"city": "SAN JOSE",
"state": "CA",
"postal_code": "951262029",
"telephone_number": "408-841-7443"
}
],
"practiceLocations": [],
"basic": {
"last_name": "FORMAN",
"first_name": "MARK",
"middle_name": "D",
"credential": "PHD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2011-02-08",
"last_updated": "2011-02-08",
"status": "A"
},
"taxonomies": [
{
"code": "103T00000X",
"taxonomy_group": "",
"desc": "Psychologist",
"state": "CA",
"license": "PSY23310",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in San Jose, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 8, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.