Provider Demographics
NPI:1194713230
Name:BORUCKI, MICHAEL JOHN (MD)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOHN
Last Name:BORUCKI
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 1:1600 PROVIDENCE DR
Mailing Address - Street 2:FAMILY PRACTICE CENTER
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76707-2261
Mailing Address - Country:US
Mailing Address - Phone:254-750-8200
Mailing Address - Fax:254-750-8383
Practice Address - Street 1:1600 PROVIDENCE DR
Practice Address - Street 2:FAMILY PRACTICE CENTER
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76707-2261
Practice Address - Country:US
Practice Address - Phone:254-750-8200
Practice Address - Fax:254-750-8383
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-12
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG6777207RI0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX756.061.354OtherTPI-TEXAS PROVIDER ID
TX122949405Medicaid
TX756.061.354OtherTPI-TEXAS PROVIDER ID
TX122949405Medicaid
C13630Medicare UPIN