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General NPI Number Information
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NPI Number | 1972552271
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Entity Type | Individual
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Provider Name | JESSE SANDOVAL D.O.
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Gender | Male
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Dates
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Enumeration Date | 05/06/2006
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Last Update Date | 12/19/2023
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Provider Practice Location Address
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Address Line | 245 N BINKLEY ST STE 101
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City | SOLDOTNA
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State | AK
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Zip | 99669-7500
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Country | US
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Telephone | 907-714-4111
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Fax | 907-262-5191
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Provider Business Mailing Address
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Address Line | PO BOX 7130
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City | BOISE
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State | ID
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Zip | 83707-1130
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Country | US
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Telephone | 208-333-1472
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Fax | 208-333-7757
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 0124
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 202K00000X
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Taxonomy Name | Phlebology Physician
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License Number | O124
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License Number State | ID
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