Healthcare Provider Details

I. General information

NPI: 1215946702
Provider Name (Legal Business Name): EVETTA LAVERN BORDEN DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 09/01/2023
Certification Date: 09/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 E STONER AVE
SHREVEPORT LA
71101-4243
US

IV. Provider business mailing address

614 WESTMORELAND DR
HINESVILLE GA
31313-4419
US

V. Phone/Fax

Practice location:
  • Phone: 912-977-0584
  • Fax:
Mailing address:
  • Phone: 912-977-0584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberPOD000770
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: