Provider Demographics
NPI:1972527380
Name:BORDEN, PETER S (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:S
Last Name:BORDEN
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 1:23456 HAWTHORNE BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4716
Mailing Address - Country:US
Mailing Address - Phone:310-375-8700
Mailing Address - Fax:310-375-8776
Practice Address - Street 1:23456 HAWTHORNE BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4716
Practice Address - Country:US
Practice Address - Phone:310-375-8700
Practice Address - Fax:310-375-8776
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62201174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6332760001OtherNATIONAL SUPPLIER CLEARINGHOUSE
CAA62201Medicare ID - Type UnspecifiedSTATE LIC
CA6332760001OtherNATIONAL SUPPLIER CLEARINGHOUSE
CAH25128Medicare UPIN