Basic Information
| Provider Information | |||||||||
| NPI: | 1598723231 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOREN | ||||||||
| FirstName: | EDWIN | ||||||||
| MiddleName: | LAWRENCE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1820 PRESTON PARK BLVD | ||||||||
| Address2: | 1825 | ||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750933656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9728677862 | ||||||||
| FaxNumber: | 9726121623 | ||||||||
| Practice Location | |||||||||
| Address1: | 3901 W 15TH ST | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9725966800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 05/09/2016 | ||||||||
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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 | 2085R0202X | K9489 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 113749901 | 05 | TX | MEDICAID | 89274R | 01 | TX | COLLIN COUNTY PTAN | OTHER |