Provider Demographics
NPI:1942202106
Name:SORENSEN, RUSSELL LAMAR (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:LAMAR
Last Name:SORENSEN
Suffix:
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 1:9844 S 1300 E
Mailing Address - Street 2:STE 250
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-4691
Mailing Address - Country:US
Mailing Address - Phone:801-571-1552
Mailing Address - Fax:801-571-1562
Practice Address - Street 1:9844 S 1300 E
Practice Address - Street 2:STE 250
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-4691
Practice Address - Country:US
Practice Address - Phone:801-571-1552
Practice Address - Fax:801-571-1562
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1638911205207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Not Answered207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1638911205OtherSTATE LICENSE
UTD07469Medicare UPIN