Provider Demographics
NPI:1609135300
Name:SOORENA SADRI DPM PA
Entity Type:Organization
Organization Name:SOORENA SADRI DPM PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SOORENA
Authorized Official - Middle Name:
Authorized Official - Last Name:SADRI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:239-590-8860
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:239-590-8860
Practice Address - Fax:949-577-4813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-15
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6506AOtherBLUE SHIELD
FLP01066091OtherRAILROAD MEDICARE
FLGJ048ZMedicare PIN