Healthcare Provider Details

I. General information

NPI: 1679577258
Provider Name (Legal Business Name): DARRELL ALLEN SORAH JR. OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 03/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 CHURCH ST
WINDER GA
30680-1714
US

IV. Provider business mailing address

P O BOX 608
WINDER GA
30680-0608
US

V. Phone/Fax

Practice location:
  • Phone: 770-867-2505
  • Fax: 770-867-8668
Mailing address:
  • Phone: 770-867-2505
  • Fax: 770-867-8668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1513
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: