Provider Demographics
NPI:1932265246
Name:PAOLI BREBAN, WALDEMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:WALDEMAR
Middle Name:
Last Name:PAOLI BREBAN
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:A 12 GUANINA
Mailing Address - Street 2:VILLA BORINQUEN
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00725
Mailing Address - Country:US
Mailing Address - Phone:787-607-0353
Mailing Address - Fax:
Practice Address - Street 1:BO PASO SECO RD 153
Practice Address - Street 2:SECTOR EL OJO 456
Practice Address - City:SANTA ISABEL
Practice Address - State:PR
Practice Address - Zip Code:00757
Practice Address - Country:US
Practice Address - Phone:787-845-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15582174400000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR22993Medicare ID - Type UnspecifiedMEDICARE