Provider Demographics
NPI:1033195896
Name:SEQUEIRA, MARIO JOSE (MD)
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:JOSE
Last Name:SEQUEIRA
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 1:1286 S FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955
Mailing Address - Country:US
Mailing Address - Phone:321-636-7780
Mailing Address - Fax:321-636-1152
Practice Address - Street 1:1286 S FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955
Practice Address - Country:US
Practice Address - Phone:321-636-7780
Practice Address - Fax:321-636-1152
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME75673207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL070011947OtherRR MEDICARE
FL254392300Medicaid
FL43330Medicare ID - Type Unspecified
G62997Medicare UPIN