Provider Demographics
NPI:1720420557
Name:ANCELLO, SARA ELIZABETH (DO)
Entity Type:Individual
Prefix:DR
First Name:SARA
Middle Name:ELIZABETH
Last Name:ANCELLO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3638 E SOUTHERN AVE STE C108
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-2563
Mailing Address - Country:US
Mailing Address - Phone:480-834-0771
Mailing Address - Fax:480-834-1136
Practice Address - Street 1:3638 E SOUTHERN AVE STE C108
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-2563
Practice Address - Country:US
Practice Address - Phone:480-834-0771
Practice Address - Fax:480-834-1136
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-22
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ007159207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ526023Medicaid