Basic Information
| Provider Information | |||||||||
| NPI: | 1134359854 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BORJA | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | PAOLO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BORJA | ||||||||
| OtherFirstName: | PAOLO | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6355 S BUFFALO DR FL 3 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891132133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022163346 | ||||||||
| FaxNumber: | 7026716883 | ||||||||
| Practice Location | |||||||||
| Address1: | 4490 N RANCHO DR | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891303406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026550550 | ||||||||
| FaxNumber: | 7026550545 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2009 | ||||||||
| LastUpdateDate: | 09/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | DO3047 | NV | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | OS 10650 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1908 | 01 | FL | QUALITY HEALTH PLANS-LARGO OFFICE | OTHER | 1909 | 01 | FL | QUALITY HEALTH PLANS-PASADENA OFFIE | OTHER | P112544 | 01 | FL | FREEDOM HEALTH | OTHER | 1134359854 | 05 | NV | MEDICAID | 1907 | 01 | FL | QUALITY HEALTH PLANS-49TH STREET OFFICE | OTHER | DO3047 | 01 | NV | STATE LICENSE | OTHER | 201266825 | 01 | FL | TRICARE-ALL LOCATIONS | OTHER |