Provider Demographics
NPI:1659363828
Name:SANDOVAL, EPIFANIO GLORIA (MD)
Entity Type:Individual
Prefix:
First Name:EPIFANIO
Middle Name:GLORIA
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8400 LOUISIANA ST
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6385
Mailing Address - Country:US
Mailing Address - Phone:219-757-1928
Mailing Address - Fax:219-757-1950
Practice Address - Street 1:3903 INDIANAPOLIS BLVD
Practice Address - Street 2:
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312-2555
Practice Address - Country:US
Practice Address - Phone:219-398-7050
Practice Address - Fax:219-392-6998
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030388A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100325110Medicaid
IN000000213350OtherANTHEM BC/BS
IN100325110Medicaid
IN945770TTMedicare PIN