Healthcare Provider Details

I. General information

NPI: 1750370110
Provider Name (Legal Business Name): MYRIAM MONDESTIN SORRENTINO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MYRIAM A.J MONDESTIN SORRENTINO MD

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 02/12/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 WASHINGTON AVE # 1100
EVANSVILLE IN
47714-0541
US

IV. Provider business mailing address

213 MATCHAPONIX AVE
MONROE NJ
08831-4080
US

V. Phone/Fax

Practice location:
  • Phone: 812-485-1894
  • Fax: 812-485-1870
Mailing address:
  • Phone: 732-521-3617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberMD448921
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License NumberMD448921
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number25MA06923000
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number25MA06923000
License Number StateNJ
# 5
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number01095225A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: