Basic Information
| Provider Information | |||||||||
| NPI: | 1184600918 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDOVAL | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | P. O. BOX 29441 | ||||||||
| Address2: | 8401 DATEPOINT SUITE 600 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782290441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106167700 | ||||||||
| FaxNumber: | 2106167709 | ||||||||
| Practice Location | |||||||||
| Address1: | 8401 DATAPOINT DR STE 600 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782295907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106167700 | ||||||||
| FaxNumber: | 2106167709 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 04/09/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | K2997 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085R0202X | K2997 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085U0001X | K2997 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound |
ID Information
| ID | Type | State | Issuer | Description | 8L26728 | 01 | TX | MEDICARE - STRIC | OTHER | 1446304-05 | 05 | TX | MEDICAID | 1446304-04 | 05 | TX | MEDICAID | P00829953 | 01 | TX | RAILROAD MEDICARE | OTHER | 1446304-03 | 05 | TX | MEDICAID | K2997 | 01 | TX | TEXAS MEDICAL LICENSE | OTHER | P00845684 | 01 | TX | RAILROAD MEDICARE | OTHER |