Provider Demographics
NPI:1225590821
Name:RIVERA SEPULVEDA, JOSE ALFREDO (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ALFREDO
Last Name:RIVERA 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:PO BOX 3594
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00681-3594
Mailing Address - Country:US
Mailing Address - Phone:939-940-6670
Mailing Address - Fax:
Practice Address - Street 1:405 S COLLEGE ST
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-5409
Practice Address - Country:US
Practice Address - Phone:478-621-2072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-02
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR35269-R207R00000X
390200000X
GA94290207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program