1902004989 NPI number — DR. SARA FITZGERALD CUBENAS O.D.

Table of content: JOHN ALDRICH N ALEJANDRO NP (NPI 1891242293)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902004989 NPI number — DR. SARA FITZGERALD CUBENAS O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CUBENAS
Provider First Name:
SARA
Provider Middle Name:
FITZGERALD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FITZGERALD
Provider Other First Name:
SARA
Provider Other Middle Name:
DIANE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
O.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1902004989
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/09/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2758 ARRAN QUAY TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VALPARAISO
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46385-8050
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-309-5297
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
70 E 68TH PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERRILLVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46410-3506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-736-2020
Provider Business Practice Location Address Fax Number:
209-769-3884
Provider Enumeration Date:
07/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  18003468A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 201029210 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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