Provider Demographics
NPI:1841554284
Name:WAISBOURD, MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:WAISBOURD
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 1:840 WALNUT ST
Mailing Address - Street 2:11TH FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5109
Mailing Address - Country:US
Mailing Address - Phone:215-928-3190
Mailing Address - Fax:
Practice Address - Street 1:840 WALNUT ST
Practice Address - Street 2:11TH FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5109
Practice Address - Country:US
Practice Address - Phone:215-928-3190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD445757207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology