Provider Demographics
NPI:1366433781
Name:SEPULVADO, POLLY M (MD)
Entity type:Individual
Prefix:
First Name:POLLY
Middle Name:M
Last Name:SEPULVADO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:573 NE STEPHENS ST
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-3150
Mailing Address - Country:US
Mailing Address - Phone:541-677-2432
Mailing Address - Fax:541-957-1131
Practice Address - Street 1:150 NE KENNETH FORD DR
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-1042
Practice Address - Country:US
Practice Address - Phone:416-729-5965
Practice Address - Fax:541-492-2060
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD16468207RR0500X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR005129Medicaid
ORR0000BJBWJMedicare PIN
OR005129Medicaid