Provider Demographics
NPI:1407931108
Name:SEPULVEDA, PEDRO (MD)
Entity Type:Individual
Prefix:
First Name:PEDRO
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 1:910 SAN PEDRO AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-4642
Mailing Address - Country:US
Mailing Address - Phone:210-222-9575
Mailing Address - Fax:210-222-9531
Practice Address - Street 1:910 SAN PEDRO AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-4642
Practice Address - Country:US
Practice Address - Phone:210-222-9575
Practice Address - Fax:210-222-9531
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6238174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF86910Medicare UPIN
TX00731GMedicare ID - Type UnspecifiedMEDICARE