Provider Demographics
NPI:1396000840
Name:SANDOVAL, WILFREDO (OD)
Entity Type:Individual
Prefix:
First Name:WILFREDO
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2320 BOB BULLOCK LOOP
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78043
Mailing Address - Country:US
Mailing Address - Phone:956-286-7680
Mailing Address - Fax:
Practice Address - Street 1:2320 BOB BULLOCK LOOP
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78043-9772
Practice Address - Country:US
Practice Address - Phone:956-286-7680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8109TG152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management