Provider Demographics
NPI:1407934961
Name:MACHALA, SARAH A (OD)
Entity Type:Individual
Prefix:DR
First Name:SARAH
Middle Name:A
Last Name:MACHALA
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 1:991 GALENA SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:GALENA
Mailing Address - State:IL
Mailing Address - Zip Code:61036-1355
Mailing Address - Country:US
Mailing Address - Phone:815-777-2440
Mailing Address - Fax:815-777-2240
Practice Address - Street 1:991 GALENA SQUARE DR
Practice Address - Street 2:
Practice Address - City:GALENA
Practice Address - State:IL
Practice Address - Zip Code:61036-1355
Practice Address - Country:US
Practice Address - Phone:815-777-2440
Practice Address - Fax:815-777-2240
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009683152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046009683Medicaid
ILV03278Medicare UPIN
IL215828Medicare PIN
ILK19653Medicare ID - Type UnspecifiedMEMBER #