Healthcare Provider Details

I. General information

NPI: 1285330779
Provider Name (Legal Business Name): VIDA SELENA SANDOVAL MD, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 10/28/2023
Certification Date: 10/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 16TH ST FL 4
SAN FRANCISCO CA
94143-0110
US

IV. Provider business mailing address

550 16TH ST FL 4
SAN FRANCISCO CA
94143-0110
US

V. Phone/Fax

Practice location:
  • Phone: 415-476-5001
  • Fax:
Mailing address:
  • Phone: 415-476-5001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number12280
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: