Healthcare Provider Details

I. General information

NPI: 1164740221
Provider Name (Legal Business Name): SARA MAE EDEIKEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2010
Last Update Date: 10/15/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 COLISEUM DR STE 200
HAMPTON VA
23666-5963
US

IV. Provider business mailing address

3000 COLISEUM DR STE 200
HAMPTON VA
23666-5963
US

V. Phone/Fax

Practice location:
  • Phone: 757-224-2198
  • Fax:
Mailing address:
  • Phone: 757-224-2198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number0101283876
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberMD482465
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberS0280
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: