Provider Demographics
NPI:1508146663
Name:KOEHNEMANN, SARAH ELIZABETH (OD)
Entity Type:Individual
Prefix:DR
First Name:SARAH
Middle Name:ELIZABETH
Last Name:KOEHNEMANN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:SARAH
Other - Middle Name:ELIZABETH
Other - Last Name:BREHM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:338 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-3548
Mailing Address - Country:US
Mailing Address - Phone:321-269-2021
Mailing Address - Fax:
Practice Address - Street 1:338 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-3548
Practice Address - Country:US
Practice Address - Phone:321-269-2021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-22
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007767152W00000X
FLOPC4676152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008836600Medicaid
FLGJ700ZMedicare PIN