Provider Demographics
NPI:1285330779
Name:SANDOVAL, VIDA SELENA (MD, MPH)
Entity type:Individual
Prefix:
First Name:VIDA
Middle Name:SELENA
Last Name:SANDOVAL
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 16TH ST FL 4
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-0110
Mailing Address - Country:US
Mailing Address - Phone:415-476-5001
Mailing Address - Fax:
Practice Address - Street 1:550 16TH ST FL 4
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-0110
Practice Address - Country:US
Practice Address - Phone:415-476-5001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-06
Last Update Date:2023-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12280208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics