Provider Demographics
NPI:1407829526
Name:SOROKO, THERESA ANN (MD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:ANN
Last Name:SOROKO
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:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:CEDAR GROVE
Mailing Address - State:NJ
Mailing Address - Zip Code:07009
Mailing Address - Country:US
Mailing Address - Phone:973-748-4583
Mailing Address - Fax:973-748-3243
Practice Address - Street 1:199 BROAD ST
Practice Address - Street 2:SUITE 2A
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003
Practice Address - Country:US
Practice Address - Phone:973-748-4583
Practice Address - Fax:973-748-3243
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05040300207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2101700Medicaid
NJ2101700Medicaid
NJ612533Medicare ID - Type Unspecified