Provider Demographics
NPI:1619993524
Name:SEPULVEDA, RICARDO
Entity Type:Individual
Prefix:DR
First Name:RICARDO
Middle Name:
Last Name:SEPULVEDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2218
Mailing Address - Country:US
Mailing Address - Phone:517-787-6440
Mailing Address - Fax:517-787-4146
Practice Address - Street 1:6757 ARAPAHO RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-4005
Practice Address - Country:US
Practice Address - Phone:972-488-8926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9661207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX030191302Medicaid
TX030191303Medicaid
TX030191302Medicaid
TX8C0852Medicare PIN