1770574857 NPI number — STEPHEN LAWRENCE BORODKIN M.D.

Table of content: STEPHEN LAWRENCE BORODKIN M.D. (NPI 1770574857)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770574857 NPI number — STEPHEN LAWRENCE BORODKIN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BORODKIN
Provider First Name:
STEPHEN
Provider Middle Name:
LAWRENCE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.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:
1770574857
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4776 E GUADALUPE RD
Provider Second Line Business Mailing Address:
APT #3084
Provider Business Mailing Address City Name:
GILBERT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85234-7501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-955-5553
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1255 EAST BROADWAY ROAD
Provider Second Line Business Practice Location Address:
SUITE 240
Provider Business Practice Location Address City Name:
TEMPE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85282
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-929-5100
Provider Business Practice Location Address Fax Number:
480-731-1066
Provider Enumeration Date:
10/28/2005

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: 2084P0800X , with the licence number:  25516 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2084P0800X , with the licence number: 11357 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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