Provider Demographics
NPI:1629244231
Name:SEPULVEDA, MARTIN-JOSE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN-JOSE
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 1:294 ROUTE 100
Mailing Address - Street 2:
Mailing Address - City:SOMERS
Mailing Address - State:NY
Mailing Address - Zip Code:10589-3202
Mailing Address - Country:US
Mailing Address - Phone:914-766-8399
Mailing Address - Fax:
Practice Address - Street 1:412 PLANTATION GROVE LN
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-9120
Practice Address - Country:US
Practice Address - Phone:203-550-9982
Practice Address - Fax:904-501-1136
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-03
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL125724207R00000X
CT031307207R00000X
CAG41317207R00000X
VA0101232778207R00000X
NC9901609207R00000X
NY163043207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine