Provider Demographics
NPI:1265796932
Name:BORDELON, SEAN DAVID (MD)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:DAVID
Last Name:BORDELON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:251 E ONTARIO ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3044
Mailing Address - Country:US
Mailing Address - Phone:312-926-2000
Mailing Address - Fax:
Practice Address - Street 1:446 E ONTARIO ST
Practice Address - Street 2:7-200
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4418
Practice Address - Country:US
Practice Address - Phone:312-926-8058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-27
Last Update Date:2017-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1250611602084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL125061160Medicare Oscar/Certification