Provider Demographics
NPI:1396858502
Name:BORDERS, CAMILLE A (MD)
Entity Type:Individual
Prefix:DR
First Name:CAMILLE
Middle Name:A
Last Name:BORDERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 W 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46402-1703
Mailing Address - Country:US
Mailing Address - Phone:219-880-1190
Mailing Address - Fax:219-880-0784
Practice Address - Street 1:1021 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46402-1703
Practice Address - Country:US
Practice Address - Phone:219-880-1190
Practice Address - Fax:219-880-0784
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056527174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL00000262992OtherANTHEM PROVIDER ID NO.
IN200394130Medicaid