Provider Demographics
NPI:1750370110
Name:MONDESTIN SORRENTINO, MYRIAM (MD)
Entity type:Individual
Prefix:
First Name:MYRIAM
Middle Name:
Last Name:MONDESTIN SORRENTINO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MYRIAM
Other - Middle Name:AJ
Other - Last Name:MONDESTIN SORRENTINO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:213 MATCHAPONIX AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NJ
Mailing Address - Zip Code:08831-4080
Mailing Address - Country:US
Mailing Address - Phone:732-521-3617
Mailing Address - Fax:
Practice Address - Street 1:3700 WASHINGTON AVE # 1100
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-0541
Practice Address - Country:US
Practice Address - Phone:812-485-1894
Practice Address - Fax:812-485-1870
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD448921207VG0400X, 207VM0101X
NJ25MA06923000207V00000X, 207VM0101X
IN01095225A207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8575703Medicaid
NJH35377Medicare UPIN
NJ047111Medicare PIN