Provider Demographics
NPI:1043494016
Name:GREGG S. SORENSEN, MD
Entity Type:Organization
Organization Name:GREGG S. SORENSEN, MD
Other - Org Name:WILLOW PASS MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGG
Authorized Official - Middle Name:SYNDER
Authorized Official - Last Name:SORENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:925-890-3356
Mailing Address - Street 1:53 MANOR DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:BAY POINT
Mailing Address - State:CA
Mailing Address - Zip Code:94565-6647
Mailing Address - Country:US
Mailing Address - Phone:925-890-3356
Mailing Address - Fax:925-945-1417
Practice Address - Street 1:53 MANOR DR
Practice Address - Street 2:SUITE A
Practice Address - City:BAY POINT
Practice Address - State:CA
Practice Address - Zip Code:94565-6647
Practice Address - Country:US
Practice Address - Phone:925-458-6125
Practice Address - Fax:925-458-8513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55173207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0030700Medicaid
CAGR0030700Medicaid
CAA52886Medicare UPIN