Provider Demographics
NPI:1467668798
Name:TISDALE, SARA E (MD)
Entity Type:Individual
Prefix:DR
First Name:SARA
Middle Name:E
Last Name:TISDALE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6001 E WOODMEN RD
Mailing Address - Street 2:RM 5242
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80923-2601
Mailing Address - Country:US
Mailing Address - Phone:719-571-5242
Mailing Address - Fax:719-571-5248
Practice Address - Street 1:6001 E WOODMEN RD
Practice Address - Street 2:RM 5242
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80923-2601
Practice Address - Country:US
Practice Address - Phone:719-571-5242
Practice Address - Fax:719-571-5248
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO45990208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO99753570Medicaid