Provider Demographics
NPI:1306528096
Name:SEPULVEDA ROSADO, DIEGO JAVIER
Entity type:Individual
Prefix:
First Name:DIEGO
Middle Name:JAVIER
Last Name:SEPULVEDA ROSADO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3950 CARR 176 APT 30
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-6611
Mailing Address - Country:US
Mailing Address - Phone:787-515-0694
Mailing Address - Fax:
Practice Address - Street 1:100 GRAND PASEO BLVD
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926-5905
Practice Address - Country:US
Practice Address - Phone:787-283-2555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-02
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3041390200000X
PR2658390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program