Provider Demographics
NPI:1407864366
Name:SANDBERG, MICHELLE SUSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:SUSAN
Last Name:SANDBERG
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 1:297 PARK LANE
Mailing Address - Street 2:
Mailing Address - City:ATHERTON
Mailing Address - State:CA
Mailing Address - Zip Code:94027
Mailing Address - Country:US
Mailing Address - Phone:650-906-5002
Mailing Address - Fax:
Practice Address - Street 1:750 S BASCOM AVE
Practice Address - Street 2:SANTA CLARA VALLEY MEDICAL CENTER DEPT OF PEDIATRICS
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128
Practice Address - Country:US
Practice Address - Phone:408-885-4706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA75749208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics