Provider Demographics
NPI:1356518146
Name:BORRA, VIJAY (MD)
Entity type:Individual
Prefix:
First Name:VIJAY
Middle Name:
Last Name:BORRA
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:PO BOX 2129
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79760-2129
Mailing Address - Country:US
Mailing Address - Phone:432-640-6446
Mailing Address - Fax:432-640-6493
Practice Address - Street 1:519 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4429
Practice Address - Country:US
Practice Address - Phone:432-640-6446
Practice Address - Fax:432-640-6493
Is Sole Proprietor?:No
Enumeration Date:2008-05-12
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY245506207X00000X
TXN9355207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX307655601Medicaid
TXTXB166179Medicare PIN