Healthcare Provider Details

I. General information

NPI: 1699778589
Provider Name (Legal Business Name): MARK ANTONIO BORDEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 03/04/2022
Certification Date: 03/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4712 N ARMENIA AVE STE 102
TAMPA FL
33603-2611
US

IV. Provider business mailing address

4712 N ARMENIA AVE STE 102
TAMPA FL
33603-2611
US

V. Phone/Fax

Practice location:
  • Phone: 813-879-5716
  • Fax: 813-877-4890
Mailing address:
  • Phone: 813-879-5716
  • Fax: 813-877-4890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME74322
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: