=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174558506
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JORGE CEPEDA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2006
-----------------------------------------------------
Last Update Date | 11/02/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 485 W MARKET ST
-----------------------------------------------------
City | TIFFIN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44883
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-447-3130
-----------------------------------------------------
Fax | 419-448-3155
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1108
-----------------------------------------------------
City | ANN ARBOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48106-1108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-677-7400
-----------------------------------------------------
Fax | 734-677-7407
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 35039173C
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------