Provider Demographics
NPI:1356335897
Name:SORENSEN, ROBERT A (OD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:SORENSEN
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 1:8445 N GOVERNMENT WAY
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-9280
Mailing Address - Country:US
Mailing Address - Phone:208-772-3208
Mailing Address - Fax:208-762-2574
Practice Address - Street 1:8445 N GOVERNMENT WAY
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-9280
Practice Address - Country:US
Practice Address - Phone:208-772-3208
Practice Address - Fax:208-762-2574
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-963152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U66635Medicare UPIN
ID1592947Medicare ID - Type Unspecified