Provider Demographics
NPI:1649266941
Name:SORUM, PAUL CLAY (MD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:CLAY
Last Name:SORUM
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 1:724 WATERVLIET SHAKER RD
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-3528
Mailing Address - Country:US
Mailing Address - Phone:518-783-0312
Mailing Address - Fax:518-782-7485
Practice Address - Street 1:724 WATERVLIET SHAKER RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-3528
Practice Address - Country:US
Practice Address - Phone:518-783-0312
Practice Address - Fax:518-782-7485
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY157754-1207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00894486Medicaid
NY00894486Medicaid
NY36183EMedicare ID - Type Unspecified