Provider Demographics
NPI:1700866258
Name:MODERT, SARA KNEEDLER (DO)
Entity Type:Individual
Prefix:DR
First Name:SARA
Middle Name:KNEEDLER
Last Name:MODERT
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:PO BOX 802
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-0017
Mailing Address - Country:US
Mailing Address - Phone:618-244-1234
Mailing Address - Fax:
Practice Address - Street 1:1 DOCTORS PARK RD STE C
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864
Practice Address - Country:US
Practice Address - Phone:618-244-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036079217207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036079217Medicaid
L69159Medicare ID - Type Unspecified
IL036079217Medicaid