Healthcare Provider Details

I. General information

NPI: 1376566497
Provider Name (Legal Business Name): VESTA SANDOVAL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 09/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 WALTER NE STE 206
ALBUQUERQUE NM
87102
US

IV. Provider business mailing address

500 WALTER ST NE STE 501
ALBUQUERQUE NM
87102-2521
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-2350
  • Fax: 505-727-2355
Mailing address:
  • Phone: 505-727-3170
  • Fax: 505-727-3171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number98330
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number98330
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number98330
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: