Healthcare Provider Details

I. General information

NPI: 1669446282
Provider Name (Legal Business Name): JOSE A. DEBORJA D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2006
Last Update Date: 07/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 DUTCHMANS LN SUITE C
EASTON MD
21601
US

IV. Provider business mailing address

PO BOX 705
EASTON MD
21601-8912
US

V. Phone/Fax

Practice location:
  • Phone: 410-822-0991
  • Fax: 410-822-0577
Mailing address:
  • Phone: 410-822-0991
  • Fax: 410-822-0577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number01268
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number01268
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: