Provider Demographics
NPI:1164982203
Name:BORNSTEIN, MARK (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BORNSTEIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1964 W 11 MILE RD
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072
Mailing Address - Country:US
Mailing Address - Phone:248-544-9300
Mailing Address - Fax:248-544-1148
Practice Address - Street 1:1964 11 MILE RD
Practice Address - Street 2:
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-3046
Practice Address - Country:US
Practice Address - Phone:248-544-9300
Practice Address - Fax:248-544-1148
Is Sole Proprietor?:No
Enumeration Date:2019-03-24
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101026804207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine