Healthcare Provider Details

I. General information

NPI: 1366519167
Provider Name (Legal Business Name): JAIME LUIS SEPULVEDA MD, FACOG, FACS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 10/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 SUNSET DR SUITE 504
SOUTH MIAMI FL
33143-4828
US

IV. Provider business mailing address

6200 SUNSET DR SUITE 504
SOUTH MIAMI FL
33143-4828
US

V. Phone/Fax

Practice location:
  • Phone: 305-669-6167
  • Fax: 305-669-6815
Mailing address:
  • Phone: 305-669-6167
  • Fax: 305-669-6815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License NumberME57803
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: