Provider Demographics
NPI:1043283146
Name:KURTIS, SARA R (OD)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:R
Last Name:KURTIS
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 1:3930 44TH AVENUE DR
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6401
Mailing Address - Country:US
Mailing Address - Phone:309-736-2280
Mailing Address - Fax:309-736-2288
Practice Address - Street 1:3930 44TH AVENUE DR
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6401
Practice Address - Country:US
Practice Address - Phone:309-736-2280
Practice Address - Fax:309-736-2288
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04821476OtherBCBS
IL0476210001OtherMEDICARE DME
IL04821476OtherBCBS
ILK23659Medicare ID - Type Unspecified