Provider Demographics
NPI:1558302810
Name:PADILLA BADILLO, VIVIANA (MD)
Entity Type:Individual
Prefix:
First Name:VIVIANA
Middle Name:
Last Name:PADILLA BADILLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PMB 120 PO BOX 4960
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00726-4960
Mailing Address - Country:US
Mailing Address - Phone:787-319-5455
Mailing Address - Fax:787-653-8385
Practice Address - Street 1:PLAZA DEL CARMEN MALL 24
Practice Address - Street 2:
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725
Practice Address - Country:US
Practice Address - Phone:787-319-5455
Practice Address - Fax:787-653-8385
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15635208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRI26549Medicare UPIN
PR002-3001Medicare ID - Type Unspecified