Provider Demographics
NPI:1053502815
Name:SORENSON, CHARLES W (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:W
Last Name:SORENSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 10TH AVE STE 178
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84103-2885
Mailing Address - Country:US
Mailing Address - Phone:801-408-2500
Mailing Address - Fax:801-408-1410
Practice Address - Street 1:324 10TH AVE STE 178
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84103-2885
Practice Address - Country:US
Practice Address - Phone:801-408-2500
Practice Address - Fax:801-408-1410
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1641971205208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000011362Medicare PIN