Healthcare Provider Details

I. General information

NPI: 1699963983
Provider Name (Legal Business Name): WANDA SEPULVEDA OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2007
Last Update Date: 02/15/2024
Certification Date: 02/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1498 FD ROOSEVELT STE 16
GUAYNABO PR
00968-2735
US

IV. Provider business mailing address

215 CALLE MANUEL ROSSY BALDRICH
SAN JUAN PR
00918-4311
US

V. Phone/Fax

Practice location:
  • Phone: 787-783-1085
  • Fax:
Mailing address:
  • Phone: 787-998-0317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number161
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: