MEDICARE: DR. KEVIN C SORENSEN O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	4879	OH

General Provider Information

NPI Number	:	1508919960
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEVIN C SORENSEN O.D.

Provider Business Mailing Address
First Line	:	2186 HARRIS AVE NE STE 1
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32905-4044
Country	:	US
Telephone Number	:	321-724-2020
Fax Number	:

Provider Business Practice Location Address
First Line	:	2186 HARRIS AVE NE STE 1
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32905-4044
Country	:	US
Telephone Number	:	321-724-2020
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/19/2007
Last Update Date	:	04/25/2022

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