Provider Demographics
NPI:1922154988
Name:SEPULVEDA, JOSE A (LIC)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:A
Last Name:SEPULVEDA
Suffix:
Gender:M
Credentials:LIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UR. EL RETIRO 30 CALLE CIBELES
Mailing Address - Street 2:
Mailing Address - City:SAN GERMAN
Mailing Address - State:PR
Mailing Address - Zip Code:00683
Mailing Address - Country:US
Mailing Address - Phone:787-892-5881
Mailing Address - Fax:787-892-5881
Practice Address - Street 1:42 CALLE DR SANTIAGO VEVE
Practice Address - Street 2:
Practice Address - City:SAN GERMAN
Practice Address - State:PR
Practice Address - Zip Code:00683-4052
Practice Address - Country:US
Practice Address - Phone:787-892-5881
Practice Address - Fax:787-892-5881
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1328291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory