Provider Demographics
NPI:1760020739
Name:ABU-SABA, MATILDA MARTA (MD)
Entity type:Individual
Prefix:
First Name:MATILDA
Middle Name:MARTA
Last Name:ABU-SABA
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 1:12409 CLARK ST APT 201
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-7685
Mailing Address - Country:US
Mailing Address - Phone:407-920-6688
Mailing Address - Fax:
Practice Address - Street 1:5970 CHURCHVIEW DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-2574
Practice Address - Country:US
Practice Address - Phone:815-971-8990
Practice Address - Fax:815-971-9978
Is Sole Proprietor?:No
Enumeration Date:2019-12-20
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036164993207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program