Provider Demographics
NPI:1619978780
Name:SABBAGH, IRA M (DO)
Entity Type:Individual
Prefix:
First Name:IRA
Middle Name:M
Last Name:SABBAGH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 10TH ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-5262
Mailing Address - Country:US
Mailing Address - Phone:810-985-8170
Mailing Address - Fax:810-985-4660
Practice Address - Street 1:1209 10TH ST
Practice Address - Street 2:SUITE E
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-5262
Practice Address - Country:US
Practice Address - Phone:810-985-8170
Practice Address - Fax:810-985-4660
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010323207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3164698Medicaid
MI3164689Medicaid
MI3164698Medicaid