Provider Demographics
NPI:1003342494
Name:SEPULVEDA GARCIA, LUIS RUBEN
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:RUBEN
Last Name:SEPULVEDA GARCIA
Suffix:
Gender:M
Credentials:
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 14
Mailing Address - Street 2:
Mailing Address - City:YABUCOA
Mailing Address - State:PR
Mailing Address - Zip Code:00767-0014
Mailing Address - Country:US
Mailing Address - Phone:787-391-1716
Mailing Address - Fax:
Practice Address - Street 1:PUERTO RICO MEDICAL CENTER
Practice Address - Street 2:HOSPITAL UNIVERSITARIO DE ADULTOS
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921
Practice Address - Country:US
Practice Address - Phone:787-777-3535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR22687208D00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program