Healthcare Provider Details

I. General information

NPI: 1992915490
Provider Name (Legal Business Name): BORIS MORDKOVICH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 01/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 SYLVAN AVE SUITE 202
ENGLEWOOD CLIFFS NJ
07632-3049
US

IV. Provider business mailing address

96 LINWOOD PLZ #307
FORT LEE NJ
07024-3701
US

V. Phone/Fax

Practice location:
  • Phone: 201-751-9490
  • Fax: 201-751-9491
Mailing address:
  • Phone: 201-751-9490
  • Fax: 201-751-9491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery
License Number25MA08107700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: