Provider Demographics
NPI:1952490336
Name:BORCHERT, GARY A
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:A
Last Name:BORCHERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:273 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46176-1101
Mailing Address - Country:US
Mailing Address - Phone:317-398-8299
Mailing Address - Fax:317-398-8411
Practice Address - Street 1:273 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SHELBYVILLE
Practice Address - State:IN
Practice Address - Zip Code:46176-1101
Practice Address - Country:US
Practice Address - Phone:317-398-8299
Practice Address - Fax:317-398-8411
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002294152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100464100AMedicaid
INT65077Medicare UPIN
IN100464100AMedicaid
IN0925420001Medicare NSC