Provider Demographics
NPI:1407840119
Name:SEPPALA, FAY E (MD)
Entity Type:Individual
Prefix:DR
First Name:FAY
Middle Name:E
Last Name:SEPPALA
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 1:1371 N 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:STAYTON
Mailing Address - State:OR
Mailing Address - Zip Code:97383-2037
Mailing Address - Country:US
Mailing Address - Phone:503-769-3785
Mailing Address - Fax:503-769-3741
Practice Address - Street 1:1371 N 10TH AVE
Practice Address - Street 2:
Practice Address - City:STAYTON
Practice Address - State:OR
Practice Address - Zip Code:97383-2037
Practice Address - Country:US
Practice Address - Phone:503-769-3785
Practice Address - Fax:503-769-3741
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-08
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD26361208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR005788Medicaid
OR005788Medicaid