Provider Demographics
NPI:1740230044
Name:BORDEN, RENAE SUE (OD)
Entity Type:Individual
Prefix:MRS
First Name:RENAE
Middle Name:SUE
Last Name:BORDEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:RENAE
Other - Middle Name:SUE
Other - Last Name:ROBINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2725 SE NOTTINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64063-3662
Mailing Address - Country:US
Mailing Address - Phone:816-882-4900
Mailing Address - Fax:
Practice Address - Street 1:600 NE CORONADO DR
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014
Practice Address - Country:US
Practice Address - Phone:816-224-3838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03472152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U77761Medicare UPIN
MOU77761Medicare UPIN