Provider Demographics
NPI:1316171994
Name:SANDOVAL, JEFF J (IDMT)
Entity type:Individual
Prefix:MR
First Name:JEFF
Middle Name:J
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 AMDS SGOPF
Mailing Address - Street 2:1090 ARNOLD DR
Mailing Address - City:LITTLE ROCK AFB
Mailing Address - State:AR
Mailing Address - Zip Code:72099-0001
Mailing Address - Country:US
Mailing Address - Phone:501-987-6810
Mailing Address - Fax:
Practice Address - Street 1:19 AMDS SGOPF
Practice Address - Street 2:1090 ARNOLD DR
Practice Address - City:LITTLE ROCK AFB
Practice Address - State:AR
Practice Address - Zip Code:72099-0001
Practice Address - Country:US
Practice Address - Phone:501-987-6810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-11
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians