Provider Demographics
NPI:1063717874
Name:BIJAN SOROURI M.D. P.A.
Entity type:Organization
Organization Name:BIJAN SOROURI M.D. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KAYVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SOROURI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-453-9171
Mailing Address - Street 1:10 DARWIN DR
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19711-6658
Mailing Address - Country:US
Mailing Address - Phone:302-453-9171
Mailing Address - Fax:302-453-0732
Practice Address - Street 1:10 DARWIN DR
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19711-6658
Practice Address - Country:US
Practice Address - Phone:302-453-9171
Practice Address - Fax:302-453-0732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-26
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0003167174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000059001Medicaid
DE0000059001Medicaid