Basic Information
| Provider Information | |||||||||
| NPI: | 1376826396 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SEPULVEDA MORENO | ||||||||
| FirstName: | GONZALO | ||||||||
| MiddleName: | ALBERTO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 33 WEST END AVENUE | ||||||||
| Address2: | APT 17 A | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9178550591 | ||||||||
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| Practice Location | |||||||||
| Address1: | 635 WEST 165TH STREET | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123059535 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2011 | ||||||||
| LastUpdateDate: | 09/26/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | P81908 | NY | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.