Provider Demographics
NPI:1588703102
Name:SOBERANO, WILFREDO T (MD)
Entity type:Individual
Prefix:DR
First Name:WILFREDO
Middle Name:T
Last Name:SOBERANO
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 1:102 E ELMWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH PLAINFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07080-5216
Mailing Address - Country:US
Mailing Address - Phone:908-561-9509
Mailing Address - Fax:908-561-0653
Practice Address - Street 1:595 COUNTY AVE
Practice Address - Street 2:
Practice Address - City:SECAUCUS
Practice Address - State:NJ
Practice Address - Zip Code:07094-2605
Practice Address - Country:US
Practice Address - Phone:201-319-3667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA065978002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
018258AU6Medicare ID - Type Unspecified
G55637Medicare UPIN