Provider Demographics
NPI:1689672172
Name:SORRELLS, DONALD LYNN JR (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:LYNN
Last Name:SORRELLS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2508 BERT KOUNS INDUSTRIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3133
Mailing Address - Country:US
Mailing Address - Phone:318-212-5880
Mailing Address - Fax:318-212-5885
Practice Address - Street 1:2508 BERT KOUNS INDUSTRIAL LOOP
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3133
Practice Address - Country:US
Practice Address - Phone:318-212-5880
Practice Address - Fax:318-212-5885
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0216422086S0120X
LAMD.0216422086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1495701Medicaid
LA5E231Medicare PIN
LA1495701Medicaid
G26315Medicare UPIN
LA5E231CQ62Medicare PIN