Provider Demographics
NPI:1417120098
Name:SORINI, JONATHAN ROBERT (DO)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ROBERT
Last Name:SORINI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:38935 ANN ARBOR RD
Mailing Address - Street 2:CREDENTIALING DEPT
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-3397
Mailing Address - Country:US
Mailing Address - Phone:734-632-0175
Mailing Address - Fax:734-632-0182
Practice Address - Street 1:18101 OAKWOOD BLVD
Practice Address - Street 2:EMERGENCY DEPT
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-4089
Practice Address - Country:US
Practice Address - Phone:313-593-8780
Practice Address - Fax:313-436-2864
Is Sole Proprietor?:No
Enumeration Date:2008-04-04
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIL1152636208D00000X
MI5101017369207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1417120098Medicaid
MI12401050OtherCAQH