Provider Demographics
NPI:1710922638
Name:SORRELS, MARION JEWETT (DO)
Entity Type:Individual
Prefix:
First Name:MARION
Middle Name:JEWETT
Last Name:SORRELS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2065
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-2065
Mailing Address - Country:US
Mailing Address - Phone:601-703-3018
Mailing Address - Fax:601-703-9283
Practice Address - Street 1:1080 HIGHWAY 35 S
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:MS
Practice Address - Zip Code:39074-9423
Practice Address - Country:US
Practice Address - Phone:601-469-3555
Practice Address - Fax:601-469-3584
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18610207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00077331Medicaid
I36922Medicare UPIN
MS00077331Medicaid