Provider Demographics
NPI:1881853539
Name:BORK, JACQUELINE TOBY (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:TOBY
Last Name:BORK
Suffix:
Gender:F
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:PO BOX 64442
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4442
Mailing Address - Country:US
Mailing Address - Phone:410-706-5651
Mailing Address - Fax:410-706-4619
Practice Address - Street 1:725 W LOMBARD ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1009
Practice Address - Country:US
Practice Address - Phone:410-706-5651
Practice Address - Fax:410-706-4619
Is Sole Proprietor?:No
Enumeration Date:2008-06-07
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY255522207R00000X
390200000X
MDD77174207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD902504900Medicaid
MDS062-0553OtherCAREFIRST BC/BS
MD365734Y2ZMedicare PIN