Basic Information
| Provider Information | |||||||||
| NPI: | 1225646474 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SEPULVEDA | ||||||||
| FirstName: | LOUIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 324 GANNETT DR STE 200 | ||||||||
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| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041063266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074827861 | ||||||||
| FaxNumber: | 2074827898 | ||||||||
| Practice Location | |||||||||
| Address1: | 33 SEWALL ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041022603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078282100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2020 | ||||||||
| LastUpdateDate: | 07/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | PA2389 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1225646474 | 05 | ME | MEDICAID |