Provider Demographics
NPI:1003178013
Name:SANDOVAL, ERIC (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 S TELSHOR BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-5069
Mailing Address - Country:US
Mailing Address - Phone:575-521-5385
Mailing Address - Fax:
Practice Address - Street 1:1111 SOUTH ST.LOUIS AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74120-5440
Practice Address - Country:US
Practice Address - Phone:918-619-3395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-14
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRS2012-0466207Q00000X
NMMD2014-0755207Q00000X
OK32151207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine