Provider Demographics
NPI:1023161791
Name:SANDHOLM, JUSTIN E (OD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:E
Last Name:SANDHOLM
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 1:35 HCOS/CC
Mailing Address - Street 2:PSC 76 UNIT 5024
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96319-5024
Mailing Address - Country:US
Mailing Address - Phone:071-677-6269
Mailing Address - Fax:
Practice Address - Street 1:35 HCOS/CC
Practice Address - Street 2:PSC 76 UNIT 5024
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96319-5024
Practice Address - Country:US
Practice Address - Phone:071-677-6269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11738152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU91589Medicare UPIN