Provider Demographics
NPI:1629152103
Name:HERSTAD, SARA C (DO)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:C
Last Name:HERSTAD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:C
Other - Last Name:BRUNS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3909 NEW VISION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1725
Practice Address - Country:US
Practice Address - Phone:260-469-6610
Practice Address - Fax:260-969-3065
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02003108A207Q00000X, 207Q00000X
MN62900207Q00000X
IL036143957207Q00000X
WI67867-21207Q00000X
OK6189207Q00000X
CA15956207Q00000X
IDOC-0014207Q00000X
WY11419C207Q00000X
NVCL0023207Q00000X
WAOP60847677207Q00000X
AZ007645207Q00000X
MTMED-PHYS-LIC-66385207Q00000X
CO49410207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200832180Medicaid
CO26176564Medicaid
CO021274OtherKAISER COMMERCIAL NUMBER
CO021274OtherKAISER COMMERCIAL NUMBER