Provider Demographics
NPI:1518922368
Name:SORENSON, SHAWN C (OD)
Entity Type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:C
Last Name:SORENSON
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 1:355 S EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-5912
Mailing Address - Country:US
Mailing Address - Phone:208-938-2015
Mailing Address - Fax:208-938-5755
Practice Address - Street 1:408 S EAGLE RD
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6078
Practice Address - Country:US
Practice Address - Phone:208-939-2773
Practice Address - Fax:208-938-5755
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-17
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-1058152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806131200Medicaid
ID806131200Medicaid
1593718Medicare ID - Type Unspecified