Provider Demographics
NPI:1174842421
Name:SEQUEDA, ROSAN MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:ROSAN
Middle Name:MARIE
Last Name:SEQUEDA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-5042
Mailing Address - Country:US
Mailing Address - Phone:386-326-7342
Mailing Address - Fax:386-325-1086
Practice Address - Street 1:712 53RD AVE E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34203-5827
Practice Address - Country:US
Practice Address - Phone:941-755-2456
Practice Address - Fax:877-788-3881
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-26
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN910208D00000X
PR17923208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRDS199AOtherPTAN