1396504882 NPI number — BRYAN OMAR SEPULVEDA BAHAMUNDI MD

Table of content: BRYAN OMAR SEPULVEDA BAHAMUNDI MD (NPI 1396504882)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396504882 NPI number — BRYAN OMAR SEPULVEDA BAHAMUNDI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SEPULVEDA BAHAMUNDI
Provider First Name:
BRYAN
Provider Middle Name:
OMAR
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1396504882
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
114 CALLE MARMOL
Provider Second Line Business Mailing Address:
URB EL PEDREGAL
Provider Business Mailing Address City Name:
SAN GERMAN
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00683
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-321-1812
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PO BOX 285
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN GERMAN
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00683-0285
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-321-1812
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/18/2024

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X , with the licence number: 17009-I , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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