Provider Demographics
NPI:1124311097
Name:BORDA, MAURICIO (MD)
Entity type:Individual
Prefix:
First Name:MAURICIO
Middle Name:
Last Name:BORDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 E 210TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2401
Mailing Address - Country:US
Mailing Address - Phone:718-920-4976
Mailing Address - Fax:
Practice Address - Street 1:3421 TELEGRAPH AVE
Practice Address - Street 2:SUITE B
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3002
Practice Address - Country:US
Practice Address - Phone:510-500-5124
Practice Address - Fax:510-380-6122
Is Sole Proprietor?:No
Enumeration Date:2011-05-25
Last Update Date:2021-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0-12-5143103K00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst