Provider Demographics
NPI:1033464458
Name:POURHEYDARIAN, SARA L (OD)
Entity Type:Individual
Prefix:DR
First Name:SARA
Middle Name:L
Last Name:POURHEYDARIAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 POPLAR LEVEL RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40213-1524
Mailing Address - Country:US
Mailing Address - Phone:502-459-2020
Mailing Address - Fax:502-456-9121
Practice Address - Street 1:4000 POPLAR LEVEL RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40213-1524
Practice Address - Country:US
Practice Address - Phone:502-459-2020
Practice Address - Fax:502-456-9121
Is Sole Proprietor?:No
Enumeration Date:2012-07-23
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1906DT152W00000X
IN18003756A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1906DTOtherKY LICENSE
KY7100227860Medicaid
KY5419240010Medicare NSC
KYK062740Medicare PIN