Provider Demographics
NPI:1114001195
Name:SKOLNICK, SARA A (MD)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:A
Last Name:SKOLNICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3336 S. PIONEEW PARKWAY
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY
Mailing Address - State:UT
Mailing Address - Zip Code:84120
Mailing Address - Country:US
Mailing Address - Phone:801-250-9638
Mailing Address - Fax:
Practice Address - Street 1:3336 S. PIONEEW PARKWAY
Practice Address - Street 2:
Practice Address - City:WEST VALLEY
Practice Address - State:UT
Practice Address - Zip Code:84120
Practice Address - Country:US
Practice Address - Phone:801-250-9638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA68765207V00000X
TXL3130207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A687650Medicaid
00A687650Medicare ID - Type Unspecified
H51305Medicare UPIN