Provider Demographics
NPI:1306800404
Name:BORDERS, JACK C JR (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:C
Last Name:BORDERS
Suffix:JR
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 1:333 N SANTA ROSA
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-3108
Mailing Address - Country:US
Mailing Address - Phone:210-704-3342
Mailing Address - Fax:
Practice Address - Street 1:333 N SANTA ROSA
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-3108
Practice Address - Country:US
Practice Address - Phone:210-704-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA039054207YP0228X
TXU4672207YP0228X
WI3792207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000617801FMedicaid
GA000617801BMedicaid
GA202I045467Medicare PIN