Provider Demographics
NPI:1912212846
Name:GOLDBERG, MICHELE SARA (MD)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:SARA
Last Name:GOLDBERG
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 1:409 W 400 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84101-1135
Mailing Address - Country:US
Mailing Address - Phone:801-364-0058
Mailing Address - Fax:801-359-4568
Practice Address - Street 1:409 W 400 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-1135
Practice Address - Country:US
Practice Address - Phone:801-364-0058
Practice Address - Fax:801-359-4568
Is Sole Proprietor?:No
Enumeration Date:2010-08-16
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD5611281207Q00000X
UT9881082-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine