Basic Information
| Provider Information | |||||||||
| NPI: | 1790931541 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDOVAL | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | DE LOS ANGELES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315 N SAN SABA ST | ||||||||
| Address2: | STE 1003 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782073108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2107043718 | ||||||||
| FaxNumber: | 2107044520 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 N SANTA ROSA ST | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782073108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2107043718 | ||||||||
| FaxNumber: | 2107044520 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2008 | ||||||||
| LastUpdateDate: | 02/09/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N2774 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics | 208M00000X | N2774 | TX | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 205044503 | 05 | TX | MEDICAID | N2774 | 01 | TX | ST LIC | OTHER | 8CS891 | 01 | TX | BCBS | OTHER | 205044504 | 01 | TX | CSN | OTHER |