Provider Demographics
NPI:1942350079
Name:BORUCKI, SIMON (MD)
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:
Last Name:BORUCKI
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 1:1231 CORAL WAY
Mailing Address - Street 2:
Mailing Address - City:RIVIERA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33404-2712
Mailing Address - Country:US
Mailing Address - Phone:813-476-2623
Mailing Address - Fax:
Practice Address - Street 1:1231 CORAL WAY
Practice Address - Street 2:
Practice Address - City:RIVIERA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33404-2712
Practice Address - Country:US
Practice Address - Phone:813-476-2623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018003081207P00000X
FLTRN10164207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine