1972552271 NPI number — DR. JESSE SANDOVAL D.O.

Table of content: DR. JESSE SANDOVAL D.O. (NPI 1972552271)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972552271 NPI number — DR. JESSE SANDOVAL D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SANDOVAL
Provider First Name:
JESSE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1972552271
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7130
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83707-1130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-333-1472
Provider Business Mailing Address Fax Number:
208-333-7757

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
245 N BINKLEY ST STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOLDOTNA
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99669-7500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-714-4111
Provider Business Practice Location Address Fax Number:
907-262-5191
Provider Enumeration Date:
05/06/2006

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:  0124 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 202K00000X , with the licence number: O124 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: S4620 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 200489062 . This is a "PRIMARY HEALTH NETWORK" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 200489062 . This is a "TRICARE WEST" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 0004676625 . This is a "AETNA" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 200489062 . This is a "PRINCIPAL LIFE INSURANCE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 004314700 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200489062 . This is a "MUTUAL OF OMAHA" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 200489062 . This is a "HCS HEALTH CLAIMS SERVICE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010145826 . This is a "REGENCE BLUE SHEILD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 200489062 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 200489062 . This is a "CIGNA HEALTH CARE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 200489062 . This is a "FIRST HEALTH" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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