Healthcare Provider Details

I. General information

NPI: 1760459986
Provider Name (Legal Business Name): XAVIER DIEGO SEVILLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 12/27/2023
Certification Date: 12/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 39TH ST W
BRADENTON FL
34205
US

IV. Provider business mailing address

2995 DREW ST FL 2
CLEARWATER FL
33759-3012
US

V. Phone/Fax

Practice location:
  • Phone: 941-748-4602
  • Fax: 941-747-9230
Mailing address:
  • Phone: 727-315-7496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME0076653
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: