Healthcare Provider Details

I. General information

NPI: 1396859252
Provider Name (Legal Business Name): MARK DAVID BORNSTEIN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4861 S ORANGE AVE
ORLANDO FL
32806-6949
US

IV. Provider business mailing address

4861 S ORANGE AVE
ORLANDO FL
32806-6949
US

V. Phone/Fax

Practice location:
  • Phone: 407-857-4206
  • Fax: 407-857-3893
Mailing address:
  • Phone: 407-857-4206
  • Fax: 407-857-3893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO1420
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: