Provider Demographics
NPI:1225021496
Name:BORKE, MARK W (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:BORKE
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 1:4319 GRAYS GABLE RD
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82072-6979
Mailing Address - Country:US
Mailing Address - Phone:307-742-1841
Mailing Address - Fax:
Practice Address - Street 1:1609 N ANKENY BLVD
Practice Address - Street 2:200
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-4165
Practice Address - Country:US
Practice Address - Phone:515-964-2772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY2803A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS41623Medicare PIN
WY36158Medicare UPIN