Provider Demographics
NPI:1184736720
Name:SACKS, DISA G (MD)
Entity type:Individual
Prefix:
First Name:DISA
Middle Name:G
Last Name:SACKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1282 US HIGHWAY 1
Mailing Address - Street 2:SUITE 4
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-2747
Mailing Address - Country:US
Mailing Address - Phone:321-632-4800
Mailing Address - Fax:321-632-6320
Practice Address - Street 1:1282 US HIGHWAY 1
Practice Address - Street 2:SUITE 4
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2747
Practice Address - Country:US
Practice Address - Phone:321-632-4800
Practice Address - Fax:321-632-6320
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2010-03-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME60948207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL370893400Medicaid
FL17805Medicare ID - Type Unspecified
FL370893400Medicaid