Provider Demographics
NPI:1558562645
Name:SANDOVAL, JOSHUA (IDC)
Entity Type:Individual
Prefix:MR
First Name:JOSHUA
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 CALDERA LN
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92545-9359
Mailing Address - Country:US
Mailing Address - Phone:951-259-0396
Mailing Address - Fax:
Practice Address - Street 1:MAG -39 MEDICAL
Practice Address - Street 2:CAMP PEDNLTEON
Practice Address - City:CAMP PEDNLETON
Practice Address - State:CA
Practice Address - Zip Code:92055
Practice Address - Country:US
Practice Address - Phone:760-725-2969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1710I1002XOtherINDEPENDENT DUTY CORPSMAN