MEDICARE: POLLY M SEPULVADO M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RR0500X	Rheumatology Physician	MD16468	OR
2	207R00000X	Internal Medicine Physician	MD16468	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366433781
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	POLLY M SEPULVADO M.D.

Provider Business Mailing Address
First Line	:	573 NE STEPHENS ST
Second Line	:
City	:	ROSEBURG
State	:	OR
Zip	:	97470-3150
Country	:	US
Telephone Number	:	541-677-2432
Fax Number	:	541-957-1131

Provider Business Practice Location Address
First Line	:	150 NE KENNETH FORD DR
Second Line	:
City	:	ROSEBURG
State	:	OR
Zip	:	97470-1042
Country	:	US
Telephone Number	:	416-729-5965
Fax Number	:	541-492-2060

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/03/2005
Last Update Date	:	12/09/2024

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