Provider Demographics
NPI:1780625913
Name:SANDOVAL, ROBERTO (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERTO
Middle Name:
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 1:1128 N HILL AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91104-3048
Mailing Address - Country:US
Mailing Address - Phone:626-372-3018
Mailing Address - Fax:
Practice Address - Street 1:1128 N HILL AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91104-3048
Practice Address - Country:US
Practice Address - Phone:626-372-3018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79015207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A790150Medicaid
CAH87393Medicare UPIN
CA00A790150Medicaid