Provider Demographics
NPI:1174500870
Name:PASTRYK, SARA E (OD)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:E
Last Name:PASTRYK
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 1:3424 MORMON COULEE RD
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-6750
Mailing Address - Country:US
Mailing Address - Phone:608-788-4300
Mailing Address - Fax:608-788-4325
Practice Address - Street 1:3424 MORMON COULEE RD
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-6750
Practice Address - Country:US
Practice Address - Phone:608-788-4300
Practice Address - Fax:608-788-4325
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003287A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN18003287AOtherOPTOMETRIST LICENSE
IN200498380Medicaid
IN200498380Medicaid
INV01443Medicare UPIN