Provider Demographics
NPI:1437235660
Name:SANDOVAL, EDMUNDO DAVID (MD)
Entity Type:Individual
Prefix:
First Name:EDMUNDO
Middle Name:DAVID
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:VA MEDICAL CENTER
Mailing Address - Street 2:2459 W MAIN STREET
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959
Mailing Address - Country:US
Mailing Address - Phone:618-997-5311
Mailing Address - Fax:
Practice Address - Street 1:VA MEDICAL CENTER
Practice Address - Street 2:2459 W MAIN ST
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959
Practice Address - Country:US
Practice Address - Phone:618-997-5311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL03607312207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease