Healthcare Provider Details

I. General information

NPI: 1366433781
Provider Name (Legal Business Name): POLLY M SEPULVADO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 NE KENNETH FORD DR
ROSEBURG OR
97470-1042
US

IV. Provider business mailing address

573 NE STEPHENS ST
ROSEBURG OR
97470-3150
US

V. Phone/Fax

Practice location:
  • Phone: 416-729-5965
  • Fax: 541-492-2060
Mailing address:
  • Phone: 541-677-2432
  • Fax: 541-957-1131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberMD16468
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD16468
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: