Provider Demographics
NPI:1245231190
Name:SORENSEN, DOUGLAS P (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:P
Last Name:SORENSEN
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 1:200 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3100
Mailing Address - Country:US
Mailing Address - Phone:321-724-4400
Mailing Address - Fax:321-724-1139
Practice Address - Street 1:200 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3100
Practice Address - Country:US
Practice Address - Phone:321-724-4400
Practice Address - Fax:321-724-1139
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-02
Last Update Date:2007-07-09
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
FLME0043859208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD51327Medicare UPIN
FL05506Medicare ID - Type UnspecifiedID #