Provider Demographics
NPI:1891782447
Name:BORDA, EDGAR AMISTOSO (MD)
Entity Type:Individual
Prefix:DR
First Name:EDGAR
Middle Name:AMISTOSO
Last Name:BORDA
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 1:3046 N ASHLAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-3034
Mailing Address - Country:US
Mailing Address - Phone:773-528-5851
Mailing Address - Fax:773-528-9790
Practice Address - Street 1:3046 N ASHLAND AVENUE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-3034
Practice Address - Country:US
Practice Address - Phone:773-528-5851
Practice Address - Fax:773-528-9790
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL456810Medicare ID - Type Unspecified
D15500Medicare UPIN