Provider Demographics
NPI:1396808432
Name:CROCKER-SABBAGH, IDA P (MD)
Entity type:Individual
Prefix:DR
First Name:IDA
Middle Name:P
Last Name:CROCKER-SABBAGH
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 1:10051 E DYNAMITE BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85262-5239
Mailing Address - Country:US
Mailing Address - Phone:480-473-7003
Mailing Address - Fax:
Practice Address - Street 1:10051 E DYNAMITE BLVD STE 110
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85262-5239
Practice Address - Country:US
Practice Address - Phone:480-473-7003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22798207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ529935Medicaid
AZG11136Medicare UPIN
AZ529935Medicaid