Provider Demographics
NPI:1306165402
Name:SEPULVEDA, JOE ANTHONY (MD)
Entity type:Individual
Prefix:
First Name:JOE
Middle Name:ANTHONY
Last Name:SEPULVEDA
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 1:401 QUARRY ROAD
Mailing Address - Street 2:ROOM 2204
Mailing Address - City:STANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:94025
Mailing Address - Country:US
Mailing Address - Phone:650-617-2623
Mailing Address - Fax:
Practice Address - Street 1:4065 3RD AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2184
Practice Address - Country:US
Practice Address - Phone:619-255-5120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-28
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1132832084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry