Provider Demographics
NPI:1114127263
Name:SORENSEN, MARY LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:LYNN
Last Name:SORENSEN
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 1:9220 SW BARBUR BLVD
Mailing Address - Street 2:SUITE 119-196
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-5428
Mailing Address - Country:US
Mailing Address - Phone:503-708-9804
Mailing Address - Fax:
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:L611
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-6518
Practice Address - Fax:503-494-6519
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-18
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD1580872086S0102X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORLL17317OtherOREGAN BOARD OF MEDICAL E
ORLL17711OtherOREGON MEDICAL LICENSE
ORLL18719OtherOREGON MEDICAL LICENSE
ORMD158087OtherOREGON MEDICAL LICENSE
ORFE155732OtherOREGON MEDICAL LICENSE
ORPG152564OtherOREGON MEDICAL LICENSE
ORLL15240OtherOREGON MEDICAL LICENSE
ORLL16084OtherOREGON MEDICAL LICENSE