Healthcare Provider Details

I. General information

NPI: 1891775755
Provider Name (Legal Business Name): SCOTT DAVID BORUCHOV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 DELSEA DR S STE A
GLASSBORO NJ
08028-2620
US

IV. Provider business mailing address

43 DELSEA DR S STE A
GLASSBORO NJ
08028-2620
US

V. Phone/Fax

Practice location:
  • Phone: 800-916-6067
  • Fax: 800-643-0747
Mailing address:
  • Phone: 800-916-6067
  • Fax: 800-643-0747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberCDRH.0063910
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number25MA07086700
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberCP006
License Number StateNE
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number15411C
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: