Provider Demographics
NPI:1245213081
Name:SOREY, TINA RENEE (OD)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:RENEE
Last Name:SOREY
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 1:1501 LAKELAND DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4834
Mailing Address - Country:US
Mailing Address - Phone:601-366-1085
Mailing Address - Fax:601-366-5186
Practice Address - Street 1:1501 LAKELAND DR
Practice Address - Street 2:SUITE 100
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4834
Practice Address - Country:US
Practice Address - Phone:601-366-1085
Practice Address - Fax:601-366-5186
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS637152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015291Medicaid
MS09015291Medicaid
MSU74990Medicare UPIN