Healthcare Provider Details

I. General information

NPI: 1407864366
Provider Name (Legal Business Name): MICHELLE SUSAN SANDBERG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 S BASCOM AVE SANTA CLARA VALLEY MEDICAL CENTER DEPT OF PEDIATRICS
SAN JOSE CA
95128
US

IV. Provider business mailing address

297 PARK LANE
ATHERTON CA
94027
US

V. Phone/Fax

Practice location:
  • Phone: 408-885-4706
  • Fax:
Mailing address:
  • Phone: 650-906-5002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA75749
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: