Provider Demographics
NPI:1881655207
Name:BORDELON, JOHN G (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:G
Last Name:BORDELON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1577 ROBERTS DRIVE
Mailing Address - Street 2:SUITE #323
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250
Mailing Address - Country:US
Mailing Address - Phone:904-241-9775
Mailing Address - Fax:904-249-3638
Practice Address - Street 1:1577 ROBERTS DRIVE SUITE #323
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250
Practice Address - Country:US
Practice Address - Phone:904-241-9775
Practice Address - Fax:904-249-3638
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME59137207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252394900Medicaid
FL12315YMedicare PIN
FLE88456Medicare UPIN