Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207N00000X | Dermatologist | 35-089926 | OH |
N | 207ND0101X | MOHS-Micrographic Surgeon | 228008 | MA |
Y | 207ND0101X | MOHS-Micrographic Surgeon | 35-089926 | OH |
N | 207NS0135X | Procedural Dermatology | 35-089926 | OH |
NPI | 1043242589 |
---|---|
Provider Name | Jeremy S Bordeaux |
First Address | Euclid, OH 44117-1714 |
Second Address | Worcester, MA 01605 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/07/2006 |
Last Update Date | 17/12/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000221131 | UNISON (01) | OH |
000000524092 | ANTHEM (01) | OH |
2771522 | (05) | OH |
414951 | WELLCARE (01) | OH |
5569102 | AETNA (01) | OH |
750496 | BUCKEYE (01) | OH |
P00406576 | RAILROAD MEDICARE (01) | OH |