Provider Demographics
NPI:1518023209
Name:SEVILLA, JACQUELINE SAY (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:SAY
Last Name:SEVILLA
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 1:81-715 DOCTOR CARREON BOULEVARD
Mailing Address - Street 2:SUITE A-1
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-0601
Mailing Address - Country:US
Mailing Address - Phone:760-342-2295
Mailing Address - Fax:760-342-1415
Practice Address - Street 1:81-715 DOCTOR CARREON BOULEVARD
Practice Address - Street 2:SUITE A-1
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-0601
Practice Address - Country:US
Practice Address - Phone:760-323-9309
Practice Address - Fax:760-610-8995
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA87837207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0042690Medicaid
CA00A878370Medicaid
CAI26536Medicare UPIN
CA00A878370Medicaid