Provider Demographics
NPI:1316966245
Name:BORDEN, EDWARD B (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:B
Last Name:BORDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:333 ROUTE 25A
Mailing Address - Street 2:
Mailing Address - City:ROCKY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11778-8556
Mailing Address - Country:US
Mailing Address - Phone:631-474-0707
Mailing Address - Fax:631-474-4034
Practice Address - Street 1:625 BELLE TERRE RD STE 201
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2318
Practice Address - Country:US
Practice Address - Phone:631-474-0707
Practice Address - Fax:631-474-4034
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY133133208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00718209Medicaid
NY72A241Medicare ID - Type Unspecified
NYB79086Medicare UPIN