Healthcare Provider Details

I. General information

NPI: 1861479941
Provider Name (Legal Business Name): JEFFREY S BORDERS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 03/02/2023
Certification Date: 03/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 S MAIN ST STE 200
MISHAWAKA IN
46544-2160
US

IV. Provider business mailing address

303 S MAIN ST STE 200
MISHAWAKA IN
46544-2160
US

V. Phone/Fax

Practice location:
  • Phone: 574-398-2090
  • Fax: 574-807-6752
Mailing address:
  • Phone: 574-398-2090
  • Fax: 574-807-6752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number01058854A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number10158854A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: