Basic Information
| Provider Information | |||||||||
| NPI: | 1790815157 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDOVAL | ||||||||
| FirstName: | JOB | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 350 LIBERTY ST | ||||||||
| Address2: | |||||||||
| City: | PAWCATUCK | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063791354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605999961 | ||||||||
| FaxNumber: | 8609727040 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 LIBERTY ST | ||||||||
| Address2: | |||||||||
| City: | PAWCATUCK | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063791354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605999961 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 08/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 7098 | RI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 29158 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 731424 | 01 | CONNECTICARE | OTHER | D400654480 | 01 | CT | MEDICARE | OTHER | 4095 | 01 | RI BLUE CHIP | OTHER | 010007098RL01 | 01 | CONNECTICUT BLUE CROSS | OTHER | 1790815157 | 05 | CT | MEDICAID | 41605 | 01 | RI | BLUE SHIELD | OTHER | D400737416 | 01 | CT | MEDICARE | OTHER | 9000416 | 05 | RI | MEDICAID | 9258294 | 01 | CIGNA | OTHER | 0004674595 | 01 | AETNA | OTHER | 110020788 | 01 | RI | RAILROAD MEDICARE | OTHER | 3066520 | 01 | CONNECTICUT MEDICAL ASSIS | OTHER | P02475705 | 01 | CT | RAILROAD MEDICARE | OTHER | P405784 | 01 | OXFORD | OTHER | 0400364 | 01 | UNITED HEALTH | OTHER | 0R0283 | 01 | HEALTH NET | OTHER | 41605 | 01 | FEDERAL BLUE SHIELD | OTHER | 050431424 02891 A001 | 01 | TRICARE | OTHER |