Provider Demographics
NPI:1780163006
Name:SANDOVAL, MARCOS LUIS
Entity type:Individual
Prefix:MR
First Name:MARCOS
Middle Name:LUIS
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 1:10323 RESERVE DR APT 303
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-3569
Mailing Address - Country:US
Mailing Address - Phone:831-905-0191
Mailing Address - Fax:
Practice Address - Street 1:6224 EL CAJON BLVD
Practice Address - Street 2:SUITE 17
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115
Practice Address - Country:US
Practice Address - Phone:619-287-8225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA953302967171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator