Provider Demographics
NPI:1831765668
Name:DR MARK SORRENTINO
Entity type:Organization
Organization Name:DR MARK SORRENTINO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:SORRENTINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-536-1179
Mailing Address - Street 1:403 MAIN ST STE 510
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-2107
Mailing Address - Country:US
Mailing Address - Phone:716-852-7262
Mailing Address - Fax:
Practice Address - Street 1:403 MAIN ST STE 510
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-2107
Practice Address - Country:US
Practice Address - Phone:716-852-7262
Practice Address - Fax:716-852-7267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-02
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01906587Medicaid