Provider Demographics
NPI:1992168843
Name:SANDOVAL, CARLOS (CSFA)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:SANDOVAL
Suffix:
Gender:M
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 RILEY LN
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78624-3562
Mailing Address - Country:US
Mailing Address - Phone:214-227-2457
Mailing Address - Fax:214-764-0880
Practice Address - Street 1:214 RILEY LN
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:TX
Practice Address - Zip Code:78624-3562
Practice Address - Country:US
Practice Address - Phone:214-227-2457
Practice Address - Fax:214-764-0880
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-29
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX164680246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant