Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | ME75673 | FL |
NPI | 1033195896 |
---|---|
Provider Name | Mr. Mario Jose Sequeira |
First Address | Rockledge, FL 32955 |
Second Address | Rockledge, FL 32955 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/12/2005 |
Last Update Date | 03/12/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
070011947 | RR MEDICARE (01) | FL |
254392300 | (05) | FL |
G62997 | (02) |