1790815157 NPI number — JOB L SANDOVAL MD

Table of content: JOB L SANDOVAL MD (NPI 1790815157)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790815157 NPI number — JOB L SANDOVAL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SANDOVAL
Provider First Name:
JOB
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790815157
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
350 LIBERTY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAWCATUCK
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06379-1354
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-599-9961
Provider Business Mailing Address Fax Number:
860-972-7040

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 LIBERTY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAWCATUCK
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06379-1354
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-599-9961
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  7098 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 29158 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 731424 . This is a "CONNECTICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: D400654480 . This is a "MEDICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 4095 . This is a "RI BLUE CHIP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 010007098RL01 . This is a "CONNECTICUT BLUE CROSS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1790815157 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 41605 . This is a "BLUE SHIELD" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: D400737416 . This is a "MEDICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 9000416 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9258294 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0004674595 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 110020788 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 3066520 . This is a "CONNECTICUT MEDICAL ASSIS" identifier . This identifiers is of the category "OTHER".
  • Identifier: P02475705 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: P405784 . This is a "OXFORD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0400364 . This is a "UNITED HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0R0283 . This is a "HEALTH NET" identifier . This identifiers is of the category "OTHER".
  • Identifier: 41605 . This is a "FEDERAL BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 050431424 02891 A001 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".




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