Provider Demographics
NPI:1114301298
Name:JACQUELINE SEVILLA MD A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:JACQUELINE SEVILLA MD A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SEVILLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-342-2295
Mailing Address - Street 1:81715 DOCTOR CARREON BLVD
Mailing Address - Street 2:A-1
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-0601
Mailing Address - Country:US
Mailing Address - Phone:760-323-9309
Mailing Address - Fax:760-610-8995
Practice Address - Street 1:81715 DOCTOR CARREON BLVD
Practice Address - Street 2:A-1
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-0601
Practice Address - Country:US
Practice Address - Phone:760-323-9309
Practice Address - Fax:760-610-8995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA87837207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty