Healthcare Provider Details

I. General information

NPI: 1992061030
Provider Name (Legal Business Name): MIGUEL I SANDOVAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2012
Last Update Date: 08/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E BOULDER ST
COLORADO SPRINGS CO
80909
US

IV. Provider business mailing address

PO BOX 173891
DENVER CO
80217-3891
US

V. Phone/Fax

Practice location:
  • Phone: 719-365-5000
  • Fax: 719-365-6827
Mailing address:
  • Phone: 303-306-7783
  • Fax: 303-306-7753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberBP10042717
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberBP10042717
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberRS2013-0525
License Number StateNM
# 4
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberDR.0060555
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: