Provider Demographics
NPI: | 1033267679 |
---|---|
Name: | BORDELON, JEFFREY H (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | JEFFREY |
Middle Name: | H |
Last Name: | BORDELON |
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 21850 |
Mailing Address - Street 2: | |
Mailing Address - City: | HOT SPRINGS |
Mailing Address - State: | AR |
Mailing Address - Zip Code: | 71903-1850 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 501-609-2222 |
Mailing Address - Fax: | 501-321-9689 |
Practice Address - Street 1: | 1 MERCY LN |
Practice Address - Street 2: | SUITE 201 |
Practice Address - City: | HOT SPRINGS |
Practice Address - State: | AR |
Practice Address - Zip Code: | 71913-6442 |
Practice Address - Country: | US |
Practice Address - Phone: | 501-609-2222 |
Practice Address - Fax: | 501-321-9689 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-01-08 |
Last Update Date: | 2020-07-27 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
AR | E4139 | 208M00000X |
AR | E-4139 | 207R00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | |
No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
AR | 154970001 | Medicaid | |
5N0126972 | Other | MEDICARE LINKED | |
AR | G85337 | Medicare UPIN | |
AR | 5N012 | Medicare UPIN |