Provider Demographics
NPI:1003171661
Name:BORDER, DAVID JASON (OD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JASON
Last Name:BORDER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4117 SPRING MOUNTAIN CT
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-8774
Mailing Address - Country:US
Mailing Address - Phone:661-713-0287
Mailing Address - Fax:209-538-1967
Practice Address - Street 1:3960 MITCHELL RD
Practice Address - Street 2:
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307-9420
Practice Address - Country:US
Practice Address - Phone:209-641-7813
Practice Address - Fax:209-538-1967
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-10
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14444152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGN227AMedicare UPIN