Provider Demographics
NPI:1508855669
Name:BORODKIN, JEFFREY JAY (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:JAY
Last Name:BORODKIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2820 W MARKET ST
Mailing Address - Street 2:SUITE 140
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333-4043
Mailing Address - Country:US
Mailing Address - Phone:330-253-2436
Mailing Address - Fax:330-253-2437
Practice Address - Street 1:2820 W MARKET ST
Practice Address - Street 2:SUITE 140
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-4043
Practice Address - Country:US
Practice Address - Phone:330-253-2436
Practice Address - Fax:330-253-2437
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3783152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0720483Medicaid
OH0720483Medicaid
0382540001Medicare ID - Type UnspecifiedMEDICARE DME#
BO0597873Medicare PIN
OH0720483Medicaid