Healthcare Provider Details

I. General information

NPI: 1184667347
Provider Name (Legal Business Name): WANDA IVETTE BAEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VA PONCE OUTPATIENT CLINIC 1010 PASEO DEL VETERANO AVE
PONCE PR
00718
US

IV. Provider business mailing address

HC 9 BOX 5845
SABANA GRANDE PR
00637-9629
US

V. Phone/Fax

Practice location:
  • Phone: 787-812-3030
  • Fax: 787-651-4321
Mailing address:
  • Phone: 787-812-3030
  • Fax: 787-651-4321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: