Provider Demographics
NPI:1386621597
Name:SORNABALA, SELWYN T (MD)
Entity type:Individual
Prefix:
First Name:SELWYN
Middle Name:T
Last Name:SORNABALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 WESTMORELAND CIR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-5463
Mailing Address - Country:US
Mailing Address - Phone:407-348-8886
Mailing Address - Fax:407-348-4486
Practice Address - Street 1:203 WESTMORELAND CIR
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-5463
Practice Address - Country:US
Practice Address - Phone:407-348-8886
Practice Address - Fax:407-348-4486
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87926207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL269334800Medicaid
FL43133VMedicare PIN
FL269334800Medicaid
FL43133YMedicare PIN