Provider Demographics
NPI:1205802758
Name:SORTOR, JOHN P (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:P
Last Name:SORTOR
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:684 MEDICAL CENTER DR E STE 104
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-6806
Mailing Address - Country:US
Mailing Address - Phone:559-299-7840
Mailing Address - Fax:
Practice Address - Street 1:684 MEDICAL CENTER DR E STE 104
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-6806
Practice Address - Country:US
Practice Address - Phone:559-299-7840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-24
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 5949 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0059490Medicaid
CASD0059490Medicaid
CA4177680001Medicare NSC
CASD0059490Medicare PIN