Provider Demographics
NPI:1780622282
Name:WAISBREN, BURTON A JR (MD)
Entity type:Individual
Prefix:
First Name:BURTON
Middle Name:A
Last Name:WAISBREN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BURTON
Other - Middle Name:
Other - Last Name:WAISBREN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2004 BAYSHORE RD
Mailing Address - Street 2:
Mailing Address - City:VILLAS
Mailing Address - State:NJ
Mailing Address - Zip Code:08251-1815
Mailing Address - Country:US
Mailing Address - Phone:609-465-1593
Mailing Address - Fax:866-353-5743
Practice Address - Street 1:2004 BAYSHORE RD
Practice Address - Street 2:
Practice Address - City:VILLAS
Practice Address - State:NJ
Practice Address - Zip Code:08251-1815
Practice Address - Country:US
Practice Address - Phone:609-465-1593
Practice Address - Fax:866-353-5743
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04698000207RC0000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0069850Medicaid
NJ0069850Medicaid
NJA61888Medicare UPIN
NJ439121Medicare PIN