Provider Demographics
NPI:1841232899
Name:BORDWELL, WILLIAM A (OD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:A
Last Name:BORDWELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 S CENTER ST
Mailing Address - Street 2:
Mailing Address - City:GENESEO
Mailing Address - State:IL
Mailing Address - Zip Code:61254-1338
Mailing Address - Country:US
Mailing Address - Phone:309-944-5303
Mailing Address - Fax:309-944-3465
Practice Address - Street 1:112 S CENTER ST
Practice Address - Street 2:
Practice Address - City:GENESEO
Practice Address - State:IL
Practice Address - Zip Code:61254-1338
Practice Address - Country:US
Practice Address - Phone:309-944-5303
Practice Address - Fax:309-944-3465
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007958152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0526490001Medicare NSC
ILT39043Medicare UPIN
IL782360Medicare ID - Type Unspecified