Provider Demographics
NPI:1902004989
Name:CUBENAS, SARA FITZGERALD (OD)
Entity Type:Individual
Prefix:DR
First Name:SARA
Middle Name:FITZGERALD
Last Name:CUBENAS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:SARA
Other - Middle Name:DIANE
Other - Last Name:FITZGERALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2758 ARRAN QUAY TER
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-8050
Mailing Address - Country:US
Mailing Address - Phone:219-309-5297
Mailing Address - Fax:
Practice Address - Street 1:70 E 68TH PL
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-3506
Practice Address - Country:US
Practice Address - Phone:219-736-2020
Practice Address - Fax:209-769-3884
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003468A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201029210Medicaid