Provider Demographics
NPI:1295735751
Name:BORN, FREDERICK WILLIAM (DO)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:WILLIAM
Last Name:BORN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:4077 S CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-9513
Mailing Address - Country:US
Mailing Address - Phone:269-429-2992
Mailing Address - Fax:269-429-3372
Practice Address - Street 1:4077 S CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-9513
Practice Address - Country:US
Practice Address - Phone:269-429-2992
Practice Address - Fax:269-429-3372
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-27
Last Update Date:2011-10-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI510 100 9712207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5114777Medicare ID - Type Unspecified
E 48371Medicare UPIN