Provider Demographics
NPI:1750697470
Name:BORN, DEANNA (OD)
Entity type:Individual
Prefix:
First Name:DEANNA
Middle Name:
Last Name:BORN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 S. DIXIE HIGHWAY
Mailing Address - Street 2:STE 5
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-2223
Mailing Address - Country:US
Mailing Address - Phone:217-816-4441
Mailing Address - Fax:
Practice Address - Street 1:7833 N SOUTHWOOD CIR
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-3833
Practice Address - Country:US
Practice Address - Phone:217-816-4441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-19
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4532152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003173900Medicaid