1134621097 NPI number — FERNANDO MIGUEL SEPULVEDA SANTIAGO

Table of content: FERNANDO MIGUEL SEPULVEDA SANTIAGO (NPI 1134621097)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134621097 NPI number — FERNANDO MIGUEL SEPULVEDA SANTIAGO

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:
SEPULVEDA SANTIAGO

Provider First Name:
FERNANDO

Provider Middle Name:
MIGUEL

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134621097

Entity Type Code:
Individual

Replacement NPI:

Last Update Date:
03/07/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 118

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:
MAYAGUEZ

Provider Business Mailing Address State Name:
PR

Provider Business Mailing Address Postal Code:
00681-0118

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:
787-222-7188

Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 E 210 STREET

Provider Second Line Business Practice Location Address:
ANESTHESIOLOGY

Provider Business Practice Location Address City Name:
BRONX

Provider Business Practice Location Address State Name:
NY

Provider Business Practice Location Address Postal Code:
10467

Provider Business Practice Location Address Country Code:
US

Provider Business Practice Location Address Telephone Number:
718-920-4316

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:
03/06/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

Provider Taxonomy Codes

Taxonomy code: 390200000X , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Taxonomy code: 207L00000X , with the licence number: 315649 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .