Provider Demographics
NPI:1770824112
Name:BORDEAUX, DEAN ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:DEAN
Middle Name:ROBERT
Last Name:BORDEAUX
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 1:7614 N PATTON LN
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-1828
Mailing Address - Country:US
Mailing Address - Phone:309-692-8686
Mailing Address - Fax:309-692-8741
Practice Address - Street 1:7614 N PATTON LN
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-1828
Practice Address - Country:US
Practice Address - Phone:309-692-8686
Practice Address - Fax:309-692-8741
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036031368207Q00000X
WI2743730207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine