Healthcare Provider Details

I. General information

NPI: 1972552271
Provider Name (Legal Business Name): JESSE SANDOVAL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2006
Last Update Date: 12/19/2023
Certification Date: 12/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 N BINKLEY ST STE 101
SOLDOTNA AK
99669-7500
US

IV. Provider business mailing address

PO BOX 7130
BOISE ID
83707-1130
US

V. Phone/Fax

Practice location:
  • Phone: 907-714-4111
  • Fax: 907-262-5191
Mailing address:
  • Phone: 208-333-1472
  • Fax: 208-333-7757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0124
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License NumberO124
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: