Provider Demographics
NPI:1699728766
Name:SORENSEN, GREG (OD)
Entity type:Individual
Prefix:DR
First Name:GREG
Middle Name:
Last Name:SORENSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1845 HAINES AVE
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-0663
Mailing Address - Country:US
Mailing Address - Phone:605-342-1157
Mailing Address - Fax:
Practice Address - Street 1:1845 HAINES AVE
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-0663
Practice Address - Country:US
Practice Address - Phone:605-342-1157
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD518152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9200210Medicaid