Provider Demographics
NPI:1790216745
Name:SANDBERG, EMILY KOSSOW (MD)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:KOSSOW
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 1:731 ALEXANDER RD STE 201
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08540-6345
Mailing Address - Country:US
Mailing Address - Phone:609-655-3800
Mailing Address - Fax:866-912-7741
Practice Address - Street 1:731 ALEXANDER RD STE 201
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:NJ
Practice Address - Zip Code:08540-6345
Practice Address - Country:US
Practice Address - Phone:609-655-3800
Practice Address - Fax:866-912-7741
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD469905207R00000X
NJ25MA11338100207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAFS9122639OtherDEA