Provider Demographics
NPI:1841778115
Name:SIEBERT, SARA MARIE (OD)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:MARIE
Last Name:SIEBERT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:MARIE
Other - Last Name:GERBERDING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2020 W ILES AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-7015
Mailing Address - Country:US
Mailing Address - Phone:217-698-3030
Mailing Address - Fax:217-698-4728
Practice Address - Street 1:106 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BEARDSTOWN
Practice Address - State:IL
Practice Address - Zip Code:62618-1241
Practice Address - Country:US
Practice Address - Phone:217-323-1146
Practice Address - Fax:217-323-1145
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011220152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046011220Medicaid