Provider Demographics
NPI:1205224722
Name:TIBURCIO, BLADIMIR
Entity Type:Individual
Prefix:
First Name:BLADIMIR
Middle Name:
Last Name:TIBURCIO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 HALSEY ST APT 401
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07102-3086
Mailing Address - Country:US
Mailing Address - Phone:973-234-6550
Mailing Address - Fax:
Practice Address - Street 1:91 HALSEY ST APT 401
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-3086
Practice Address - Country:US
Practice Address - Phone:973-234-6550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-06
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ20130004246XC2903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246XC2903XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularVascular Specialist