Provider Demographics
NPI:1114021607
Name:PAGAN, GILBERTO (PHD)
Entity Type:Individual
Prefix:DR
First Name:GILBERTO
Middle Name:
Last Name:PAGAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:467 MOUNT PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-2907
Mailing Address - Country:US
Mailing Address - Phone:973-483-0448
Mailing Address - Fax:
Practice Address - Street 1:467 MOUNT PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104-2907
Practice Address - Country:US
Practice Address - Phone:973-483-0448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJSIO 2338103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4014405Medicaid