Healthcare Provider Details

I. General information

NPI: 1740286277
Provider Name (Legal Business Name): SUSAN SANDOVAL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 07/21/2022
Certification Date: 07/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 E CENTRAL AVE
WINTER HAVEN FL
33880-3050
US

IV. Provider business mailing address

1324 LAKELAND HILLS BLVD MEDICAL STAFF OFFICE
LAKELAND FL
33805-4543
US

V. Phone/Fax

Practice location:
  • Phone: 863-284-6850
  • Fax: 863-284-6853
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME76434
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: