Provider Demographics
NPI:1841219193
Name:SORENSEN, MARK JACOB (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JACOB
Last Name:SORENSEN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:75 CLAREMONT ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3585
Mailing Address - Country:US
Mailing Address - Phone:406-752-2277
Mailing Address - Fax:406-752-5029
Practice Address - Street 1:75 CLAREMONT ST
Practice Address - Street 2:SUITE B
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3585
Practice Address - Country:US
Practice Address - Phone:406-752-2277
Practice Address - Fax:406-752-5029
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MT4265208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT810375497 59901 A001OtherTRICARE
MT0050882Medicaid
MT12270OtherBLUE CROSS OF MONTANA