Provider Demographics
NPI:1366647612
Name:BORDON, HOLLY SUZANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:SUZANNE
Last Name:BORDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:HOLLY
Other - Middle Name:SUZANNE
Other - Last Name:GIBERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:405 PASADENA AVE S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33707-2101
Mailing Address - Country:US
Mailing Address - Phone:786-390-4872
Mailing Address - Fax:
Practice Address - Street 1:405 PASADENA AVE S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33707-2101
Practice Address - Country:US
Practice Address - Phone:727-345-2212
Practice Address - Fax:727-381-3444
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME101506208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000311500Medicaid