Provider Demographics
NPI:1447571849
Name:SANDOVAL, FAREESA SHUJA (MD)
Entity Type:Individual
Prefix:
First Name:FAREESA
Middle Name:SHUJA
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:FAREESA
Other - Middle Name:
Other - Last Name:SHUJA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1760 ROUND ROCK AVE
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-4217
Mailing Address - Country:US
Mailing Address - Phone:512-583-3376
Mailing Address - Fax:512-666-3243
Practice Address - Street 1:1760 ROUND ROCK AVE
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-4217
Practice Address - Country:US
Practice Address - Phone:512-583-3376
Practice Address - Fax:512-540-8175
Is Sole Proprietor?:No
Enumeration Date:2010-06-20
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP8078207N00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX349275YS4ZMedicare PIN
TX349275YR48Medicare PIN