Provider Demographics
NPI:1881664670
Name:SANDOVAL, JOHN R (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 911244
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80291-1244
Mailing Address - Country:US
Mailing Address - Phone:719-557-4221
Mailing Address - Fax:719-557-3834
Practice Address - Street 1:1008 MINNEQUA AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3733
Practice Address - Country:US
Practice Address - Phone:719-557-4221
Practice Address - Fax:719-557-3834
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CODR-38609207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO41224060Medicaid
CO531738Medicare ID - Type Unspecified
I05519Medicare UPIN
COCO40632Medicare Oscar/Certification