Individual
DR. JESSE SANDOVAL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D.O.
Taxonomy
Speciality
Code
Description
License number
State
202K00000X
Phlebology Physician
Primary
O124
ID
207R00000X
Internal Medicine Physician
0124
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010145826
REGENCE BLUE SHEILD
ID
01
—
0004676625
AETNA
ID
05
—
004314700
—
ID
01
—
200489062
PRIMARY HEALTH NETWORK
ID
01
—
S4620
BLUE CROSS OF IDAHO
ID
Enumeration date
05/06/2006
Last updated
12/19/2023
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