Provider Demographics
NPI:1972552271
Name:SANDOVAL, JESSE (DO)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7130
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83707-1130
Mailing Address - Country:US
Mailing Address - Phone:208-333-1472
Mailing Address - Fax:208-333-7757
Practice Address - Street 1:245 N BINKLEY ST STE 101
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7500
Practice Address - Country:US
Practice Address - Phone:907-714-4111
Practice Address - Fax:907-262-5191
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-06
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID0124207R00000X
IDO124202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDS4620OtherBLUE CROSS OF IDAHO
ID200489062OtherPRIMARY HEALTH NETWORK
ID200489062OtherTRICARE WEST
ID0004676625OtherAETNA
ID200489062OtherPRINCIPAL LIFE INSURANCE
ID004314700Medicaid
ID200489062OtherMUTUAL OF OMAHA
ID200489062OtherHCS HEALTH CLAIMS SERVICE
ID000010145826OtherREGENCE BLUE SHEILD
ID200489062OtherUNITED HEALTH CARE
ID200489062OtherCIGNA HEALTH CARE
ID200489062OtherFIRST HEALTH