Provider Demographics
NPI:1225327174
Name:DIEBOLD, SARA GREENE
Entity type:Individual
Prefix:MISS
First Name:SARA
Middle Name:GREENE
Last Name:DIEBOLD
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 1:2995 DREW ST
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-3012
Mailing Address - Country:US
Mailing Address - Phone:727-281-9065
Mailing Address - Fax:
Practice Address - Street 1:4712 N ARMENIA AVE STE 102
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-2611
Practice Address - Country:US
Practice Address - Phone:813-879-5716
Practice Address - Fax:813-877-2611
Is Sole Proprietor?:No
Enumeration Date:2011-03-31
Last Update Date:2025-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME169340208000000X
KY47488208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100315080Medicaid
KYK360020OtherKY MEDICARE
KY000000897766OtherANTHEM
KY50077879OtherPASSPORT HEALTH PLAN