Provider Demographics
NPI:1679631659
Name:BORDIUK, GREGORY WILLIAM (DPM)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:WILLIAM
Last Name:BORDIUK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WEST LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07764-1308
Mailing Address - Country:US
Mailing Address - Phone:732-571-1366
Mailing Address - Fax:732-571-1366
Practice Address - Street 1:1000 BROADWAY
Practice Address - Street 2:
Practice Address - City:WEST LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07764-1308
Practice Address - Country:US
Practice Address - Phone:732-571-1366
Practice Address - Fax:732-571-1366
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00147700213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1434004Medicaid
NJ1434004Medicaid
NJ102618Medicare ID - Type Unspecified