Provider Demographics
NPI:1104039593
Name:KROCKOVER, MITZI ROSE (MD)
Entity Type:Individual
Prefix:DR
First Name:MITZI
Middle Name:ROSE
Last Name:KROCKOVER
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 1:5685 N SCOTTSDALE RD
Mailing Address - Street 2:E100
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85250-5900
Mailing Address - Country:US
Mailing Address - Phone:480-707-4521
Mailing Address - Fax:
Practice Address - Street 1:5685 N SCOTTSDALE RD
Practice Address - Street 2:E100
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85250-5900
Practice Address - Country:US
Practice Address - Phone:480-707-4521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48336207R00000X
KY34681207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY34681OtherMEDICAL LICENSE
CAA48336OtherMEDICAL LICENSE