Provider Demographics
NPI:1689677312
Name:MAYMI-BURGOS, WANDA E (MD)
Entity Type:Individual
Prefix:MISS
First Name:WANDA
Middle Name:E
Last Name:MAYMI-BURGOS
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:VILLA CARMEN B 11
Mailing Address - Street 2:BOX 5533
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00726
Mailing Address - Country:US
Mailing Address - Phone:787-745-1235
Mailing Address - Fax:787-745-1235
Practice Address - Street 1:B11 VILLA CARMEN
Practice Address - Street 2:
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725-5414
Practice Address - Country:US
Practice Address - Phone:787-745-1235
Practice Address - Fax:787-745-1235
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-26
Last Update Date:2021-02-19
Deactivation Date:2006-03-30
Deactivation Code:
Reactivation Date:2006-03-30
Provider Licenses
StateLicense IDTaxonomies
PRPR10858208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
G37952Medicare UPIN
MA83159Medicare PIN