Provider Demographics
NPI:1699893693
Name:BOURDON MALDONADO, HERIBERTO (MD)
Entity type:Individual
Prefix:DR
First Name:HERIBERTO
Middle Name:
Last Name:BOURDON MALDONADO
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:PO BOX 78
Mailing Address - Street 2:
Mailing Address - City:VILLALBA
Mailing Address - State:PR
Mailing Address - Zip Code:00766-0078
Mailing Address - Country:US
Mailing Address - Phone:787-847-2368
Mailing Address - Fax:787-847-1305
Practice Address - Street 1:HOSPITAL SAN LUCAS LOBBY C SUITE 3
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00731
Practice Address - Country:US
Practice Address - Phone:787-844-2080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6677207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRD95873Medicare UPIN