Healthcare Provider Details

I. General information

NPI: 1871790147
Provider Name (Legal Business Name): BORKO B DJORDJEVIC M.D., PHD., F.I.C.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8680 MONROE CT SUITES 100 & 200
RANCHO CUCAMONGA CA
91730-4880
US

IV. Provider business mailing address

PO BOX 2788
RANCHO CUCAMONGA CA
91729-2788
US

V. Phone/Fax

Practice location:
  • Phone: 909-483-1700
  • Fax: 909-989-6682
Mailing address:
  • Phone: 909-483-1700
  • Fax: 909-989-6682

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberCA A31228
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: