Provider Demographics
NPI:1770563272
Name:SANDOVAL, JUAN
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 BARNES LN
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-4402
Mailing Address - Country:US
Mailing Address - Phone:718-485-2420
Mailing Address - Fax:
Practice Address - Street 1:9413 FLATLANDS AVE
Practice Address - Street 2:SUITE 206E
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236
Practice Address - Country:US
Practice Address - Phone:718-485-2420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY235394207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01981093Medicaid
NY01981093Medicaid
NY52G561Medicare ID - Type Unspecified