Provider Demographics
NPI:1518078351
Name:BORNSTEIN, MARK IRA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:IRA
Last Name:BORNSTEIN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 RIVERFRONT BLVD STE 710
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34205-8812
Mailing Address - Country:US
Mailing Address - Phone:941-776-4000
Mailing Address - Fax:941-845-4963
Practice Address - Street 1:725 N 12TH AVE BLDG B
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:FL
Practice Address - Zip Code:34266-8752
Practice Address - Country:US
Practice Address - Phone:863-494-1242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-004534103TC0700X
FLPY11422103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4932021OtherBLUE CROSS/BLUE SHIELD
IL4932021OtherBLUE CROSS/BLUE SHIELD
203373Medicare ID - Type Unspecified