Provider Demographics
NPI:1083647747
Name:BORNSTEIN, ILAN D (MD)
Entity Type:Individual
Prefix:
First Name:ILAN
Middle Name:D
Last Name:BORNSTEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1 AMALIA DR
Mailing Address - Street 2:
Mailing Address - City:BUCKHANNON
Mailing Address - State:WV
Mailing Address - Zip Code:26201-2239
Mailing Address - Country:US
Mailing Address - Phone:304-473-2300
Mailing Address - Fax:304-460-7988
Practice Address - Street 1:1255 STATE ROAD 60 E
Practice Address - Street 2:SUITE 400
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4310
Practice Address - Country:US
Practice Address - Phone:863-678-2272
Practice Address - Fax:863-679-6870
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV24269207V00000X
FLME125210207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVWV2309AMedicare PIN