Healthcare Provider Details

I. General information

NPI: 1831770882
Provider Name (Legal Business Name): MARK OLIVER VICERRA BORJA OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2021
Last Update Date: 04/20/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 W 40TH ST
BALTIMORE MD
21211-2140
US

IV. Provider business mailing address

3632 WILLOW ST
HAMPSTEAD MD
21074-1890
US

V. Phone/Fax

Practice location:
  • Phone: 410-235-8660
  • Fax:
Mailing address:
  • Phone: 410-382-8628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA4265
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number09257
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: