Provider Demographics
NPI:1710979778
Name:BORROMEO, VIDAL D (MD)
Entity Type:Individual
Prefix:DR
First Name:VIDAL
Middle Name:D
Last Name:BORROMEO
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 1:5505 WING LAKE RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48301-1250
Mailing Address - Country:US
Mailing Address - Phone:248-626-0829
Mailing Address - Fax:
Practice Address - Street 1:60 W BIG BEAVER RD
Practice Address - Street 2:STE. 130
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-3909
Practice Address - Country:US
Practice Address - Phone:248-644-7355
Practice Address - Fax:248-644-6840
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIVB031765207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI40645OtherBLUE CARE NETWORK
MI40645OtherBLUE CARE NETWORK
MI0630490Medicare ID - Type Unspecified