Basic Information
| Provider Information | |||||||||
| NPI: | 1881647071 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SORENSEN | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1345 W CENTRAL PARK AVE | ||||||||
| Address2: | |||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528041844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5634214400 | ||||||||
| FaxNumber: | 5634214449 | ||||||||
| Practice Location | |||||||||
| Address1: | 1345 W CENTRAL PARK AVE | ||||||||
| Address2: | |||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528041844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5634214400 | ||||||||
| FaxNumber: | 5634214449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 05/14/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 31344 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8128298 | 05 | IA | MEDICAID |