Provider Demographics
NPI:1699137646
Name:HOLMBERG, PAULINE RAQUEL (MD)
Entity type:Individual
Prefix:
First Name:PAULINE
Middle Name:RAQUEL
Last Name:HOLMBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 KILLDEER RD
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06517-3529
Mailing Address - Country:US
Mailing Address - Phone:323-459-5901
Mailing Address - Fax:
Practice Address - Street 1:464 CONGRESS AVE STE 260
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1362
Practice Address - Country:US
Practice Address - Phone:203-737-2644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-28
Last Update Date:2020-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA168222207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program