Provider Demographics
NPI:1164425757
Name:SEPULVEDA, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SEPULVEDA
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 1:342 VIA VAQUERO SUR
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN BAUTISTA
Mailing Address - State:CA
Mailing Address - Zip Code:95045-9307
Mailing Address - Country:US
Mailing Address - Phone:831-325-6459
Mailing Address - Fax:
Practice Address - Street 1:342 VIA VAQUERO SUR
Practice Address - Street 2:
Practice Address - City:SAN JUAN BAUTISTA
Practice Address - State:CA
Practice Address - Zip Code:95045-9307
Practice Address - Country:US
Practice Address - Phone:831-325-6459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64123174400000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH52317Medicare UPIN
CAH52317Medicare UPIN