Healthcare Provider Details

I. General information

NPI: 1992190821
Provider Name (Legal Business Name): SARA DE LA ROSA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2015
Last Update Date: 12/09/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 E MOUND RD
DECATUR IL
62526-2099
US

IV. Provider business mailing address

2020 W ILES AVE
SPRINGFIELD IL
62704-4174
US

V. Phone/Fax

Practice location:
  • Phone: 217-877-5050
  • Fax: 217-877-9711
Mailing address:
  • Phone: 217-698-3030
  • Fax: 217-698-4728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number0101266362
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036154010
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: