Basic Information
| Provider Information | |||||||||
| NPI: | 1235266131 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BORNFELD | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 622 W DUARTE RD | ||||||||
| Address2: | 101 | ||||||||
| City: | ARCADIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910077606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264462122 | ||||||||
| FaxNumber: | 6264460513 | ||||||||
| Practice Location | |||||||||
| Address1: | 622 W DUARTE RD | ||||||||
| Address2: | 101 | ||||||||
| City: | ARCADIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910077606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264462122 | ||||||||
| FaxNumber: | 6264460513 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 02/01/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT5505 | CA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | SD0055050 | 01 | CA | BLUE SHILED | OTHER | SD0055050 | 05 | CA | MEDICAID |