Healthcare Provider Details

I. General information

NPI: 1619044435
Provider Name (Legal Business Name): MARIALUZ SEVILLA-HERRERA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 04/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 S SUNSET AVE STE 211
WEST COVINA CA
91790-3938
US

IV. Provider business mailing address

1135 S SUNSET AVE STE 211
WEST COVINA CA
91790-3938
US

V. Phone/Fax

Practice location:
  • Phone: 626-337-1800
  • Fax: 626-337-1449
Mailing address:
  • Phone: 626-337-1800
  • Fax: 626-337-1449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA66370
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: