Provider Demographics
NPI:1043242589
Name:BORDEAUX, JEREMY S (MD MPH)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:S
Last Name:BORDEAUX
Suffix:
Gender:M
Credentials:MD MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24701 EUCLID AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44117-1714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:281 LINCOLN STREET
Practice Address - Street 2:UMASS DERMATOLOGY HAHNEMANN CAMPUS
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605
Practice Address - Country:US
Practice Address - Phone:508-334-5971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-089926207N00000X, 207NS0135X, 207ND0101X
MA228008207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2771522Medicaid
OH000000524092OtherANTHEM
OHP00406576OtherRAILROAD MEDICARE
OH000000221131OtherUNISON
OH750496OtherBUCKEYE
OH5569102OtherAETNA
OH414951OtherWELLCARE
OH2771522Medicaid