Provider Demographics
NPI:1396000840
Name:SANDOVAL, WILFREDO (OD)
Entity type:Individual
Prefix:
First Name:WILFREDO
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:OPA LOCKA
Mailing Address - State:FL
Mailing Address - Zip Code:33054-3954
Mailing Address - Country:US
Mailing Address - Phone:956-286-7680
Mailing Address - Fax:
Practice Address - Street 1:4813 SW 8TH ST
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-2522
Practice Address - Country:US
Practice Address - Phone:786-431-1635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8109TG152WC0802X
FLOPC5086152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management