Provider Demographics
NPI:1184600918
Name:SANDOVAL, KENNETH A (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P. O. BOX 29441
Mailing Address - Street 2:8401 DATEPOINT SUITE 600
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-0441
Mailing Address - Country:US
Mailing Address - Phone:210-616-7700
Mailing Address - Fax:210-616-7709
Practice Address - Street 1:8401 DATAPOINT DR STE 600
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-5907
Practice Address - Country:US
Practice Address - Phone:210-616-7700
Practice Address - Fax:210-616-7709
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2016-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK29972085B0100X, 2085R0202X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L26728OtherMEDICARE - STRIC
TX1446304-05Medicaid
TX1446304-04Medicaid
TXP00829953OtherRAILROAD MEDICARE
TX1446304-03Medicaid
TXK2997OtherTEXAS MEDICAL LICENSE
TXP00845684OtherRAILROAD MEDICARE
TX1446304-04Medicaid