Provider Demographics
NPI:1982612313
Name:SANDOVAL, MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 WEATHERSFIELD BOW
Mailing Address - Street 2:
Mailing Address - City:ESSEX JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05452-2645
Mailing Address - Country:US
Mailing Address - Phone:802-878-8515
Mailing Address - Fax:
Practice Address - Street 1:1 TIMBER LN
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-7205
Practice Address - Country:US
Practice Address - Phone:802-847-4714
Practice Address - Fax:802-847-6333
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420009692207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0VN1761Medicaid
VT0VN1761Medicaid
VTSAVN1761Medicare ID - Type Unspecified