Provider Demographics
NPI:1881629731
Name:PAGAN, WALLACE (MD)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:
Last Name:PAGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 URB SAN RAMON
Mailing Address - Street 2:
Mailing Address - City:SAN GERMAN
Mailing Address - State:PR
Mailing Address - Zip Code:00683-4604
Mailing Address - Country:US
Mailing Address - Phone:787-892-0048
Mailing Address - Fax:787-254-0005
Practice Address - Street 1:35 URB SAN RAMON
Practice Address - Street 2:
Practice Address - City:SAN GERMAN
Practice Address - State:PR
Practice Address - Zip Code:00683-2758
Practice Address - Country:US
Practice Address - Phone:787-892-0048
Practice Address - Fax:787-254-0005
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12739208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRH35844Medicare UPIN