Provider Demographics
NPI:1023464369
Name:DISKIN, SARA MARIE
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:MARIE
Last Name:DISKIN
Suffix:
Gender:F
Credentials:
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 933432
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0039
Mailing Address - Country:US
Mailing Address - Phone:937-641-5072
Mailing Address - Fax:
Practice Address - Street 1:1425 N FAIRFIELD RD STE 130
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45432-2674
Practice Address - Country:US
Practice Address - Phone:937-320-1950
Practice Address - Fax:937-320-9332
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-05
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35136486208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0394543Medicaid