Provider Demographics
NPI:1497742761
Name:MEDUNICK, SARA E (DO)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:E
Last Name:MEDUNICK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11058 E RAINTREE DR
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-1809
Mailing Address - Country:US
Mailing Address - Phone:610-509-5115
Mailing Address - Fax:
Practice Address - Street 1:11058 E RAINTREE DR
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-1809
Practice Address - Country:US
Practice Address - Phone:610-509-5115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-03
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07846300207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0072796Medicaid
I26599Medicare UPIN
NJ0072796Medicaid