Healthcare Provider Details

I. General information

NPI: 1033464458
Provider Name (Legal Business Name): SARA L POURHEYDARIAN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2012
Last Update Date: 04/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 POPLAR LEVEL RD
LOUISVILLE KY
40213-1524
US

IV. Provider business mailing address

4000 POPLAR LEVEL RD
LOUISVILLE KY
40213-1524
US

V. Phone/Fax

Practice location:
  • Phone: 502-459-2020
  • Fax: 502-456-9121
Mailing address:
  • Phone: 502-459-2020
  • Fax: 502-456-9121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1906DT
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18003756A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: