=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407864366
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE SUSAN SANDBERG MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 750 S BASCOM AVE SANTA CLARA VALLEY MEDICAL CENTER DEPT OF PEDIATRICS
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-885-4706
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 297 PARK LANE
-----------------------------------------------------
City | ATHERTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-906-5002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | A75749
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------