Provider Demographics
NPI:1871255406
Name:SAMARADIVAKARA, SARAH (OD)
Entity Type:Individual
Prefix:DR
First Name:SARAH
Middle Name:
Last Name:SAMARADIVAKARA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28658 WOODCHESTER WAY
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-7771
Mailing Address - Country:US
Mailing Address - Phone:760-917-9869
Mailing Address - Fax:
Practice Address - Street 1:30141 ANTELOPE RD STE G
Practice Address - Street 2:
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92584-8066
Practice Address - Country:US
Practice Address - Phone:951-679-6910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-11
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35048152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist