Healthcare Provider Details

I. General information

NPI: 1013498278
Provider Name (Legal Business Name): SARA NISAR OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2018
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3S100 ROUTE 53
GLEN ELLYN IL
60137
US

IV. Provider business mailing address

2105 W SILVERLEAF CT
ADDISON IL
60101-6403
US

V. Phone/Fax

Practice location:
  • Phone: 630-545-1090
  • Fax:
Mailing address:
  • Phone: 630-901-8055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number046.011232
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046.011232
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: