Provider Demographics
NPI:1376826396
Name:SEPULVEDA MORENO, GONZALO ALBERTO (MD)
Entity Type:Individual
Prefix:DR
First Name:GONZALO
Middle Name:ALBERTO
Last Name:SEPULVEDA MORENO
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 1:33 WEST END AVENUE
Mailing Address - Street 2:APT 17 A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023
Mailing Address - Country:US
Mailing Address - Phone:917-855-0591
Mailing Address - Fax:
Practice Address - Street 1:635 WEST 165TH STREET
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032
Practice Address - Country:US
Practice Address - Phone:212-305-9535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP81908207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology