Provider Demographics
NPI:1225047038
Name:GRODBERG, MICHELE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:
Last Name:GRODBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-3574
Mailing Address - Country:US
Mailing Address - Phone:201-567-8884
Mailing Address - Fax:201-567-5799
Practice Address - Street 1:106 GRAND AVE
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-3574
Practice Address - Country:US
Practice Address - Phone:201-567-8884
Practice Address - Fax:201-567-5799
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05620200207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ002897L9FMedicare ID - Type Unspecified
NJE62465Medicare UPIN