Healthcare Provider Details

I. General information

NPI: 1790720100
Provider Name (Legal Business Name): DIANNA L BORDEWICK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANNA L MYERS

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 08/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2253 W MASON ST STE 100
GREEN BAY WI
54303-4706
US

IV. Provider business mailing address

2253 W MASON ST STE 100 PO BOX 13097
GREEN BAY WI
54307-3097
US

V. Phone/Fax

Practice location:
  • Phone: 920-327-7000
  • Fax: 920-327-7005
Mailing address:
  • Phone: 920-327-7000
  • Fax: 920-327-7005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number41090
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: