Provider Demographics
NPI:1851593263
Name:VICENTE, WILDA ROSA (MD)
Entity Type:Individual
Prefix:DR
First Name:WILDA
Middle Name:ROSA
Last Name:VICENTE
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 1:1126 CONDOMINIO DIPLOMAT PH8
Mailing Address - Street 2:AVE ASHFORD, CONDOMINIO
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00907
Mailing Address - Country:US
Mailing Address - Phone:787-646-5118
Mailing Address - Fax:
Practice Address - Street 1:HOSPITAL PEDIATRICO UNIVERSIATIO
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00919-1079
Practice Address - Country:US
Practice Address - Phone:787-777-3535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR26040R208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics