Provider Demographics
NPI:1932145448
Name:SANDOVAL, RENATO MENDOZA (MD)
Entity Type:Individual
Prefix:DR
First Name:RENATO
Middle Name:MENDOZA
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 1:20 NE SAINT LUKES BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-6001
Mailing Address - Country:US
Mailing Address - Phone:816-347-5200
Mailing Address - Fax:816-347-5206
Practice Address - Street 1:20 N.E. SAINT LUKE'S BOULEVARD
Practice Address - Street 2:SUITE 200
Practice Address - City:LEE'S SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086
Practice Address - Country:US
Practice Address - Phone:816-347-5100
Practice Address - Fax:816-347-5173
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009017905207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1932145448Medicaid
H62721Medicare UPIN
H74000004Medicare PIN