MEDICARE: BRIAN BORDELON DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program	6950	OK
2	207R00000X	Internal Medicine Physician	T5266	TX

General Provider Information

NPI Number	:	1164984126
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN BORDELON DO

Provider Business Mailing Address
First Line	:	9701 HARMON RD STE 141
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76177-7602
Country	:	US
Telephone Number	:	817-306-5630
Fax Number	:	817-306-5631

Provider Business Practice Location Address
First Line	:	9701 HARMON RD STE 141
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76177-7602
Country	:	US
Telephone Number	:	817-306-5630
Fax Number	:	817-306-5631

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2019
Last Update Date	:	07/13/2022

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Directions to “ BRIAN BORDELON DO” Practice Location

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