Provider Demographics
NPI:1508862244
Name:BORNOVALI, SEREF (MD)
Entity Type:Individual
Prefix:
First Name:SEREF
Middle Name:
Last Name:BORNOVALI
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 1:36123 SCHOOLCRAFT RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-1216
Mailing Address - Country:US
Mailing Address - Phone:734-793-6140
Mailing Address - Fax:
Practice Address - Street 1:9633 STONEMASTERS DR
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:OH
Practice Address - Zip Code:45140-6210
Practice Address - Country:US
Practice Address - Phone:513-317-8453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.081534207R00000X
TXN6823207R00000X
IN01068901A207R00000X
KY48113207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2490102Medicaid
000000696308OtherANTHEM
000000696308OtherANTHEM
OHI02277Medicare UPIN
OH2490102Medicaid