Provider Demographics
NPI:1427054329
Name:LESTOURGEON, SARA M (MD)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:M
Last Name:LESTOURGEON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3033 N CENTRAL AVE STE 145
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2808
Mailing Address - Country:US
Mailing Address - Phone:623-583-3001
Mailing Address - Fax:623-974-6721
Practice Address - Street 1:500 W THOMAS RD STE 870
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4218
Practice Address - Country:US
Practice Address - Phone:480-964-2273
Practice Address - Fax:602-266-8358
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37049207Q00000X
AZ36703207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000277261OtherANTHEM
KY64055106Medicaid
KY64055106Medicaid
KY0538740Medicare ID - Type UnspecifiedPX
KY000000277261OtherANTHEM
KYH30950Medicare UPIN
KY0538444Medicare ID - Type UnspecifiedEB
KY64055106Medicaid