Provider Demographics
NPI:1841274313
Name:SANDOVAL, L VICTOR (OD)
Entity type:Individual
Prefix:DR
First Name:L
Middle Name:VICTOR
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 S TELSHOR BLVD
Mailing Address - Street 2:STE 1534
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4669
Mailing Address - Country:US
Mailing Address - Phone:575-522-8334
Mailing Address - Fax:575-522-1065
Practice Address - Street 1:700 S TELSHOR BLVD
Practice Address - Street 2:STE 1534
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4669
Practice Address - Country:US
Practice Address - Phone:575-522-8334
Practice Address - Fax:575-522-1065
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM260152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM99429268Medicaid
NMV08186Medicare UPIN
NM900521269Medicare PIN
NM99429268Medicaid