Provider Demographics
NPI:1790815157
Name:SANDOVAL, JOB L (MD)
Entity type:Individual
Prefix:
First Name:JOB
Middle Name:L
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:350 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:PAWCATUCK
Mailing Address - State:CT
Mailing Address - Zip Code:06379-1354
Mailing Address - Country:US
Mailing Address - Phone:860-599-9961
Mailing Address - Fax:860-972-7040
Practice Address - Street 1:350 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:PAWCATUCK
Practice Address - State:CT
Practice Address - Zip Code:06379-1354
Practice Address - Country:US
Practice Address - Phone:860-599-9961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI7098207R00000X
CT29158207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
731424OtherCONNECTICARE
CTD400654480OtherMEDICARE
4095OtherRI BLUE CHIP
010007098RL01OtherCONNECTICUT BLUE CROSS
CT1790815157Medicaid
RI41605OtherBLUE SHIELD
CTD400737416OtherMEDICARE
RI9000416Medicaid
9258294OtherCIGNA
0004674595OtherAETNA
RI110020788OtherRAILROAD MEDICARE
3066520OtherCONNECTICUT MEDICAL ASSIS
CTP02475705OtherRAILROAD MEDICARE
P405784OtherOXFORD
0400364OtherUNITED HEALTH
0R0283OtherHEALTH NET
41605OtherFEDERAL BLUE SHIELD
050431424 02891 A001OtherTRICARE