Provider Demographics
NPI:1265963888
Name:SANDOVAL, SUSANA V (MD)
Entity type:Individual
Prefix:
First Name:SUSANA
Middle Name:V
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8627 ATLANTIC AVE # 1
Mailing Address - Street 2:
Mailing Address - City:SOUTH GATE
Mailing Address - State:CA
Mailing Address - Zip Code:90280-3501
Mailing Address - Country:US
Mailing Address - Phone:888-499-9303
Mailing Address - Fax:323-312-2988
Practice Address - Street 1:8627 ATLANTIC AVE # 1
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-3501
Practice Address - Country:US
Practice Address - Phone:888-499-9303
Practice Address - Fax:323-312-2988
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-24
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA160706207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty