Basic Information
Provider Information | |||||||||
NPI: | 1770543894 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BORBOROGLU | ||||||||
FirstName: | PRODROMOS | ||||||||
MiddleName: | GORDON | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2200 W EAU GALLIE BLVD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | MELBOURNE | ||||||||
State: | FL | ||||||||
PostalCode: | 329353165 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3213085060 | ||||||||
FaxNumber: | 3213085069 | ||||||||
Practice Location | |||||||||
Address1: | 575 S WICKHAM RD | ||||||||
Address2: | SUITE A | ||||||||
City: | WEST MELBOURNE | ||||||||
State: | FL | ||||||||
PostalCode: | 329041170 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3213085060 | ||||||||
FaxNumber: | 3213085069 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/24/2006 | ||||||||
LastUpdateDate: | 05/19/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | ME99271 | FL | Y |   | Allopathic & Osteopathic Physicians | Urology |   |
ID Information
ID | Type | State | Issuer | Description | P00631812 | 01 | FL | RR MEDICARE | OTHER | 280092600 | 05 | FL |   | MEDICAID |