Provider Demographics
NPI:1740244201
Name:BORDENCA, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BORDENCA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3225 CUMBERLAND BLVD SE
Mailing Address - Street 2:SUITE 900
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-6407
Mailing Address - Country:US
Mailing Address - Phone:404-351-2220
Mailing Address - Fax:404-355-5624
Practice Address - Street 1:5445 MERIDIAN MARKS RD STE 220
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-4755
Practice Address - Country:US
Practice Address - Phone:404-255-2419
Practice Address - Fax:404-255-3101
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA48488207W00000X
GA048488207WX0110X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0110XAllopathic & Osteopathic PhysiciansOphthalmologyPediatric Ophthalmology and Strabismus Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000873848AMedicaid
GAC30849Medicare PIN
GA00965Medicare PIN
GAH13623Medicare UPIN
GA000873848AMedicaid