Healthcare Provider Details

I. General information

NPI: 1205965779
Provider Name (Legal Business Name): MR. ADRIAN SEPULVEDA SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 02/19/2024
Certification Date: 02/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 E MEDICAL CENTER BLVD
WEBSTER TX
77598-4376
US

IV. Provider business mailing address

PO BOX 890213
HOUSTON TX
77289-0213
US

V. Phone/Fax

Practice location:
  • Phone: 281-480-7832
  • Fax:
Mailing address:
  • Phone: 832-722-5767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License NumberSA00229
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: