Provider Demographics
NPI:1194776286
Name:BORCHELT, MARK D (MD, FACE)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:BORCHELT
Suffix:
Gender:M
Credentials:MD, FACE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1810
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502-1810
Mailing Address - Country:US
Mailing Address - Phone:228-867-6062
Mailing Address - Fax:228-575-2917
Practice Address - Street 1:4540 W RAILROAD ST
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2480
Practice Address - Country:US
Practice Address - Phone:228-867-6062
Practice Address - Fax:228-867-2598
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME62666207RE0101X
MS24066207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL18161YMedicare PIN