1235266131 NPI number — STEPHEN G BORNFELD O.D.

Table of content: STEPHEN G BORNFELD O.D. (NPI 1235266131)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235266131 NPI number — STEPHEN G BORNFELD O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BORNFELD
Provider First Name:
STEPHEN
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235266131
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/01/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
622 W DUARTE RD
Provider Second Line Business Mailing Address:
101
Provider Business Mailing Address City Name:
ARCADIA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91007-7606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-446-2122
Provider Business Mailing Address Fax Number:
626-446-0513

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
622 W DUARTE RD
Provider Second Line Business Practice Location Address:
101
Provider Business Practice Location Address City Name:
ARCADIA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91007-7606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-446-2122
Provider Business Practice Location Address Fax Number:
626-446-0513
Provider Enumeration Date:
02/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPT5505 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: SD0055050 . This is a "BLUE SHILED" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: SD0055050 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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