Provider Demographics
NPI:1750422259
Name:SORRENTINO, MARK (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:SORRENTINO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:403 MAIN ST
Mailing Address - Street 2:510 BRISBANE BUILDING
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-2109
Mailing Address - Country:US
Mailing Address - Phone:716-852-7262
Mailing Address - Fax:716-852-7267
Practice Address - Street 1:403 MAIN ST
Practice Address - Street 2:510 BRISBANE BUILDING
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-2109
Practice Address - Country:US
Practice Address - Phone:716-852-7262
Practice Address - Fax:716-852-7267
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY5242152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU24586Medicare UPIN
NYBB7698Medicare ID - Type Unspecified