Provider Demographics
NPI:1306945308
Name:EBERTING, CHERYL LEE DANIELLE (MD)
Entity type:Individual
Prefix:
First Name:CHERYL LEE
Middle Name:DANIELLE
Last Name:EBERTING
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:653 S HIGH BENCH RD
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:UT
Mailing Address - Zip Code:84004-1797
Mailing Address - Country:US
Mailing Address - Phone:801-763-7107
Mailing Address - Fax:801-763-7607
Practice Address - Street 1:144 S MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:ALPINE
Practice Address - State:UT
Practice Address - Zip Code:84004-1666
Practice Address - Country:US
Practice Address - Phone:801-763-7107
Practice Address - Fax:801-763-7607
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT62699311205207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZI04414Medicare UPIN