Provider Demographics
NPI:1316244817
Name:SANDOVAL-HERRERA, CARLOS (MD)
Entity type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:
Last Name:SANDOVAL-HERRERA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 S ARCHER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-6837
Mailing Address - Country:US
Mailing Address - Phone:773-523-1000
Mailing Address - Fax:773-843-1553
Practice Address - Street 1:3450 S ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-6837
Practice Address - Country:US
Practice Address - Phone:773-523-1000
Practice Address - Fax:773-843-1553
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-17
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036125201207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
367830Medicare PIN