Basic Information
| Provider Information | |||||||||
| NPI: | 1699893693 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOURDON MALDONADO | ||||||||
| FirstName: | HERIBERTO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 78 | ||||||||
| Address2: | |||||||||
| City: | VILLALBA | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007660078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878472368 | ||||||||
| FaxNumber: | 7878471305 | ||||||||
| Practice Location | |||||||||
| Address1: | HOSPITAL SAN LUCAS LOBBY C SUITE 3 | ||||||||
| Address2: | |||||||||
| City: | PONCE | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878442080 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| LastUpdateDate: | 05/20/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 6677 | PR | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.