Basic Information
| Provider Information | |||||||||
| NPI: | 1811994429 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SANDOVAL | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13460 N 94TH DR STE J1 | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853814246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238768816 | ||||||||
| FaxNumber: | 6232980168 | ||||||||
| Practice Location | |||||||||
| Address1: | 13460 N 94TH DR STE J1 | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853814246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238768816 | ||||||||
| FaxNumber: | 6232980168 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2005 | ||||||||
| LastUpdateDate: | 05/15/2019 | ||||||||
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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 | 207RC0000X | 21578 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 21578 | AZ | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 198144 | 05 | AZ | MEDICAID | P01225076 | 01 | AZ | RAILROAD MEDICARE | OTHER |