Provider Demographics
NPI:1629153697
Name:TATYANA V. BORODULIN MD, INC
Entity Type:Organization
Organization Name:TATYANA V. BORODULIN MD, INC
Other - Org Name:CAMPBELL FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:TATYANA
Authorized Official - Middle Name:V
Authorized Official - Last Name:BORODULIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-378-3330
Mailing Address - Street 1:1600 W CAMPBELL AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-1526
Mailing Address - Country:US
Mailing Address - Phone:408-375-3300
Mailing Address - Fax:408-378-6822
Practice Address - Street 1:1600 W CAMPBELL AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-1526
Practice Address - Country:US
Practice Address - Phone:408-375-3300
Practice Address - Fax:408-378-6822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ22056ZMedicare PIN