Provider Demographics
NPI:1407880057
Name:FREDRICKSON, SARA A (OD)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:A
Last Name:FREDRICKSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:A
Other - Last Name:SANT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1611 ANNE ST NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-5114
Practice Address - Country:US
Practice Address - Phone:218-333-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3005152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN375M4FROtherBLUE CROSS MN
MN539124500Medicaid
MN2202923OtherMEDICA
MN2202923OtherMEDICA