Provider Demographics
NPI:1366415770
Name:GOBLE, DESERAE JEANETTE (MD)
Entity type:Individual
Prefix:
First Name:DESERAE
Middle Name:JEANETTE
Last Name:GOBLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DESERAE
Other - Middle Name:J
Other - Last Name:GOBLE SADEGHI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1950 S HIGHWAY 89
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-4119
Mailing Address - Country:US
Mailing Address - Phone:435-363-7853
Mailing Address - Fax:435-213-3785
Practice Address - Street 1:1451 N 200 E STE 250
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-7570
Practice Address - Country:US
Practice Address - Phone:435-363-7853
Practice Address - Fax:435-213-3785
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA93148207Q00000X
UT5010200-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1366415770Medicaid
UT1366415770Medicaid
UT000061482Medicare PIN
CA00A931480Medicare ID - Type Unspecified