Provider Demographics
NPI:1508919960
Name:SORENSEN, KEVIN C (OD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:C
Last Name:SORENSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2186 HARRIS AVE NE STE 1
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-4044
Mailing Address - Country:US
Mailing Address - Phone:321-724-2020
Mailing Address - Fax:
Practice Address - Street 1:2186 HARRIS AVE NE STE 1
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-4044
Practice Address - Country:US
Practice Address - Phone:321-724-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4879152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHU78237Medicare UPIN
OHSO0887481Medicare PIN