Provider Demographics
NPI:1730248303
Name:SEPULVEDA, SONIA L
Entity type:Individual
Prefix:MRS
First Name:SONIA
Middle Name:L
Last Name:SEPULVEDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 490
Mailing Address - Street 2:
Mailing Address - City:PENUELAS
Mailing Address - State:PR
Mailing Address - Zip Code:00624
Mailing Address - Country:US
Mailing Address - Phone:787-836-2178
Mailing Address - Fax:787-826-2255
Practice Address - Street 1:#628 CALLE PEDRO VELAZQUEZ DIAZ
Practice Address - Street 2:EDIFICIO AURORA B1
Practice Address - City:PENUELAS
Practice Address - State:PR
Practice Address - Zip Code:00624
Practice Address - Country:US
Practice Address - Phone:787-836-2178
Practice Address - Fax:787-836-2255
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246QM0706X
PR975246QM0706X
PR347291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR38197Medicare PIN