Provider Demographics
NPI:1902250913
Name:O E SANDOVAL MD PC
Entity Type:Organization
Organization Name:O E SANDOVAL MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:OSCAR
Authorized Official - Middle Name:E
Authorized Official - Last Name:SANDOVAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-866-9670
Mailing Address - Street 1:569 35TH ST
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07087-2563
Mailing Address - Country:US
Mailing Address - Phone:201-866-6970
Mailing Address - Fax:201-866-7144
Practice Address - Street 1:569 35TH ST
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:NJ
Practice Address - Zip Code:07087-2563
Practice Address - Country:US
Practice Address - Phone:201-866-6970
Practice Address - Fax:201-866-7144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-15
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3585905Medicaid
NJ25MA045843OtherLICENSE
NJSA669864Medicare PIN
NJ25MA045843OtherLICENSE