Provider Demographics
NPI:1760574727
Name:SEVILLA, MARIANITO (MD)
Entity Type:Individual
Prefix:
First Name:MARIANITO
Middle Name:
Last Name:SEVILLA
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 1:2340 E 8TH ST STE D
Mailing Address - Street 2:
Mailing Address - City:NATIONAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91950-2875
Mailing Address - Country:US
Mailing Address - Phone:619-470-7007
Mailing Address - Fax:619-470-9379
Practice Address - Street 1:2340 E 8TH ST STE D
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-2875
Practice Address - Country:US
Practice Address - Phone:619-470-7007
Practice Address - Fax:619-470-9379
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37097207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A370970Medicaid
CA00A370970Medicaid
A84964Medicare UPIN