Provider Demographics
NPI:1871922369
Name:GORE, SARAH NICOLE (OD)
Entity type:Individual
Prefix:DR
First Name:SARAH
Middle Name:NICOLE
Last Name:GORE
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 1:310 W. LOSEY ST
Mailing Address - Street 2:OPTOMETRY
Mailing Address - City:SCOTT AIR FORCE BASE
Mailing Address - State:IL
Mailing Address - Zip Code:62225
Mailing Address - Country:US
Mailing Address - Phone:618-256-2392
Mailing Address - Fax:314-362-3564
Practice Address - Street 1:310 W. LOSEY ST
Practice Address - Street 2:OPTOMETRY
Practice Address - City:SCOTT AIR FORCE BASE
Practice Address - State:IL
Practice Address - Zip Code:62225
Practice Address - Country:US
Practice Address - Phone:618-256-2392
Practice Address - Fax:314-362-3564
Is Sole Proprietor?:No
Enumeration Date:2013-11-05
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013017927152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO310012306Medicaid
IL1871922369Medicaid