Provider Demographics
NPI:1801106208
Name:WEIDMAYER, SARA LYNAE (OD, FAAO)
Entity type:Individual
Prefix:DR
First Name:SARA
Middle Name:LYNAE
Last Name:WEIDMAYER
Suffix:
Gender:F
Credentials:OD, FAAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12661 SCHLEWEIS RD
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48158-9611
Mailing Address - Country:US
Mailing Address - Phone:231-580-9114
Mailing Address - Fax:
Practice Address - Street 1:1400 W MAUMEE ST
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1804
Practice Address - Country:US
Practice Address - Phone:517-265-5444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-19
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004566152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN26930216Medicare PIN