Provider Demographics
NPI:1013989987
Name:DR DOMINGO SEPULVEDA CSP
Entity Type:Organization
Organization Name:DR DOMINGO SEPULVEDA CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRICTAIN
Authorized Official - Prefix:MR
Authorized Official - First Name:DOMINGO
Authorized Official - Middle Name:
Authorized Official - Last Name:SEPULVEDA
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:787-743-3003
Mailing Address - Street 1:PO BOX 6419
Mailing Address - Street 2:
Mailing Address - City:CAGUAS
Mailing Address - State:PR
Mailing Address - Zip Code:00776-6419
Mailing Address - Country:US
Mailing Address - Phone:787-743-3003
Mailing Address - Fax:787-743-9290
Practice Address - Street 1:AVE LUIS MANOR MARIN HOSPITAL HIMA
Practice Address - Street 2:SUITE 115
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725
Practice Address - Country:US
Practice Address - Phone:787-743-3003
Practice Address - Fax:787-743-9290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4295208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty