Provider Demographics
NPI:1578555884
Name:SORTOR, JENNIFER MAZZOLA (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MAZZOLA
Last Name:SORTOR
Suffix:
Gender:F
Credentials:OD
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Mailing Address - Street 1:2433 OAK VALLEY DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-7602
Mailing Address - Country:US
Mailing Address - Phone:734-994-0100
Mailing Address - Fax:734-994-9625
Practice Address - Street 1:2433 OAK VALLEY DR
Practice Address - Street 2:SUITE 300
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-7602
Practice Address - Country:US
Practice Address - Phone:734-994-0100
Practice Address - Fax:734-994-9625
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4901004033152W00000X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4175195Medicaid
MIJS004033OtherBCBS MICHIGAN
MIU78417Medicare UPIN
MI4175195Medicaid