Healthcare Provider Details

I. General information

NPI: 1043205511
Provider Name (Legal Business Name): KENNETH R BOREN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 08/11/2020
Certification Date: 08/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4040 E MCLELLAN RD UNIT 11
MESA AZ
85205-3105
US

IV. Provider business mailing address

4040 E MCLELLAN RD UNIT 11
MESA AZ
85205-3105
US

V. Phone/Fax

Practice location:
  • Phone: 480-229-2829
  • Fax:
Mailing address:
  • Phone: 480-229-2829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number12288
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier226911
Identifier TypeMEDICAID
Identifier StateAZ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: