Provider Demographics
NPI:1972506491
Name:BORDELON, KEVIN JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JOHN
Last Name:BORDELON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4239 HIGHWAY 1192
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MARKSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71351-4771
Mailing Address - Country:US
Mailing Address - Phone:318-253-8600
Mailing Address - Fax:318-253-8654
Practice Address - Street 1:4239 HIGHWAY 1192
Practice Address - Street 2:SUITE 200
Practice Address - City:MARKSVILLE
Practice Address - State:LA
Practice Address - Zip Code:71351-4771
Practice Address - Country:US
Practice Address - Phone:318-253-8600
Practice Address - Fax:318-253-8654
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-30
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA023281207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1541729Medicaid
LA5DJ07Medicare PIN
LA1541729Medicaid
LAG74311Medicare UPIN