# MICHAEL W FORMISANO MD PA

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1639365158
- **Authorized official:** DR. MICHAEL W FORMISANO MD PA (PRESIDENT)
- **Authorized official phone:** (954) 989-4110

## Contact information

- **Practice address:** 4024 N CIRCLE DR, HOLLYWOOD, FL 33021-6726
- **Practice address phone:** (954) 989-4110
- **Practice address fax:** (954) 989-7855
- **Mailing address:** 3939 HOLLYWOOD BLVD, SUITE 2B, HOLLYWOOD, FL 33021-6749
- **Mailing address phone:** (954) 989-4110
- **Mailing address fax:** (954) 989-7855

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208D00000X | General Practice Physician | ME 91614 | FL | Yes |

## Other

- **Enumeration date:** 09/18/2007
- **Last updated:** 11/15/2007

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | ME 91614 | ME LICENSE | FL |