Provider Demographics
NPI:1699036186
Name:SANDBERG, KYLE (OD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:
Last Name:SANDBERG
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 1:4100 SOUTHWEST FWY APT 527
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77027-7455
Mailing Address - Country:US
Mailing Address - Phone:561-716-7017
Mailing Address - Fax:
Practice Address - Street 1:6565 WEST LOOP S
Practice Address - Street 2:SUITE 650
Practice Address - City:BELLAIRE
Practice Address - State:TX
Practice Address - Zip Code:77401-3500
Practice Address - Country:US
Practice Address - Phone:713-797-1010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-31
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7849TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist