Basic Information
| Provider Information | |||||||||
| NPI: | 1407833106 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDOVAL | ||||||||
| FirstName: | SYBIL | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 JORDAN LN | ||||||||
| Address2: | PRIME HEALTHCARE | ||||||||
| City: | WETHERSFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061091278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602630253 | ||||||||
| FaxNumber: | 8602630262 | ||||||||
| Practice Location | |||||||||
| Address1: | 44 DALE RD | ||||||||
| Address2: | PRIME HEALTHCARE | ||||||||
| City: | AVON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060013612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606748830 | ||||||||
| FaxNumber: | 8606748984 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2005 | ||||||||
| LastUpdateDate: | 06/21/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 032256 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 032256 | 01 | CT | MEDICAL LICENSE | OTHER | 010032256CT03 | 01 | CT | BCBS | OTHER | B53183263 | 01 | CT | DEA | OTHER |