Healthcare Provider Details

I. General information

NPI: 1902004989
Provider Name (Legal Business Name): SARA FITZGERALD CUBENAS O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SARA DIANE FITZGERALD O.D.

II. Dates (important events)

Enumeration Date: 07/11/2007
Last Update Date: 05/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 E 68TH PL
MERRILLVILLE IN
46410-3506
US

IV. Provider business mailing address

2758 ARRAN QUAY TER
VALPARAISO IN
46385-8050
US

V. Phone/Fax

Practice location:
  • Phone: 219-736-2020
  • Fax: 209-769-3884
Mailing address:
  • Phone: 219-309-5297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18003468A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: