Provider Demographics
NPI:1396504882
Name:SEPULVEDA BAHAMUNDI, BRYAN OMAR (MD)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:OMAR
Last Name:SEPULVEDA BAHAMUNDI
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 1:114 CALLE MARMOL
Mailing Address - Street 2:URB EL PEDREGAL
Mailing Address - City:SAN GERMAN
Mailing Address - State:PR
Mailing Address - Zip Code:00683
Mailing Address - Country:US
Mailing Address - Phone:787-321-1812
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 285
Practice Address - Street 2:
Practice Address - City:SAN GERMAN
Practice Address - State:PR
Practice Address - Zip Code:00683-0285
Practice Address - Country:US
Practice Address - Phone:787-321-1812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-18
Last Update Date:2024-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PR17009-I208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program