Provider Demographics
NPI:1912933268
Name:BORELLO, DAN (MD)
Entity type:Individual
Prefix:
First Name:DAN
Middle Name:
Last Name:BORELLO
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:PO BOX 3810
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803
Mailing Address - Country:US
Mailing Address - Phone:417-347-2525
Mailing Address - Fax:417-347-8991
Practice Address - Street 1:1532 W 32ND ST STE 301
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1607
Practice Address - Country:US
Practice Address - Phone:417-347-2525
Practice Address - Fax:417-347-8991
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7509207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200113207Medicaid
OK100198750AMedicaid
160052702OtherRR MEDICARE
KS100143460BMedicaid
MO6058OtherANTHEM
OK100198750AMedicaid
MO000000442Medicare PIN