Provider Demographics
NPI:1396232229
Name:BORODUNOVICH, KYLE JAMES
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:JAMES
Last Name:BORODUNOVICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5130 SUNFOREST DR STE 300
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-6327
Mailing Address - Country:US
Mailing Address - Phone:727-824-0780
Mailing Address - Fax:
Practice Address - Street 1:2812 54TH AVE S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33712-4610
Practice Address - Country:US
Practice Address - Phone:727-867-8641
Practice Address - Fax:727-867-6795
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS17309207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOS17309OtherSTATE LICENSE