Provider Demographics
NPI:1457648230
Name:KROLL, BECKY SUE (MD)
Entity Type:Individual
Prefix:
First Name:BECKY
Middle Name:SUE
Last Name:KROLL
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 1:3301 N SAWGRASS WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-4493
Mailing Address - Country:US
Mailing Address - Phone:208-375-0862
Mailing Address - Fax:208-375-2658
Practice Address - Street 1:3301 N SAWGRASS WAY
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-4493
Practice Address - Country:US
Practice Address - Phone:208-375-0862
Practice Address - Fax:208-375-2658
Is Sole Proprietor?:No
Enumeration Date:2011-06-30
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM13220207Q00000X
CAA112974207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFO226WMedicare PIN