Provider Demographics
NPI:1790720100
Name:BORDEWICK, DIANNA L (MD)
Entity Type:Individual
Prefix:
First Name:DIANNA
Middle Name:L
Last Name:BORDEWICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DIANNA
Other - Middle Name:L
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2253 W MASON ST STE 100
Mailing Address - Street 2:PO BOX 13097
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-3097
Mailing Address - Country:US
Mailing Address - Phone:920-327-7000
Mailing Address - Fax:920-327-7005
Practice Address - Street 1:2253 W MASON ST STE 100
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-4706
Practice Address - Country:US
Practice Address - Phone:920-327-7000
Practice Address - Fax:920-327-7005
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41090207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32562600Medicaid
WI180043984OtherRAILROAD
MI104390165Medicaid
WI32562600Medicaid
MI104390165Medicaid