Provider Demographics
NPI:1578792339
Name:SADRI, SOORENA (DPM)
Entity Type:Individual
Prefix:DR
First Name:SOORENA
Middle Name:
Last Name:SADRI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4956 ROYAL GULF CIR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-7006
Mailing Address - Country:US
Mailing Address - Phone:239-590-8860
Mailing Address - Fax:949-577-4813
Practice Address - Street 1:4956 ROYAL GULF CIR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-7006
Practice Address - Country:US
Practice Address - Phone:239-850-2736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-14
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC006138213ES0103X
FLPO3565213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01066091OtherRAILROAD MEDICARE
FLPO3565OtherFL LICENSE
FL6506AOtherBLUE SHIELD
FLP01066091OtherRAILROAD MEDICARE