Provider Demographics
NPI:1609694991
Name:SEPULVEDA, MIGUEL SOCORRO (CERA-5338)
Entity type:Individual
Prefix:MR
First Name:MIGUEL
Middle Name:SOCORRO
Last Name:SEPULVEDA
Suffix:
Gender:M
Credentials:CERA-5338
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 DEAN RD
Mailing Address - Street 2:
Mailing Address - City:DEPEW
Mailing Address - State:NY
Mailing Address - Zip Code:14043-1308
Mailing Address - Country:US
Mailing Address - Phone:716-553-4886
Mailing Address - Fax:
Practice Address - Street 1:371 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202-1671
Practice Address - Country:US
Practice Address - Phone:716-553-4886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-26
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYCRPA-5338175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist