Healthcare Provider Details

I. General information

NPI: 1578512844
Provider Name (Legal Business Name): MICHAEL ANTHONY SEQUEIRA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MICHAEL ANTHONY SEQUEIRA M.D

II. Dates (important events)

Enumeration Date: 05/06/2006
Last Update Date: 05/20/2020
Certification Date: 05/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

458 POTOMAC WAY
CLAREMONT CA
91711-2762
US

IV. Provider business mailing address

210 CAMPBELL AVE
REDLANDS CA
92373-6832
US

V. Phone/Fax

Practice location:
  • Phone: 909-447-0316
  • Fax: 909-447-0316
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberG64724
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberG64724
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: