Provider Demographics
NPI:1720275407
Name:TIMOTHY P. SUORSA O.D.
Entity type:Organization
Organization Name:TIMOTHY P. SUORSA O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:P
Authorized Official - Last Name:SUORSA
Authorized Official - Suffix:
Authorized Official - Credentials:O D
Authorized Official - Phone:559-784-5127
Mailing Address - Street 1:524 W PUTNAM AVE
Mailing Address - Street 2:
Mailing Address - City:PORTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93257-3274
Mailing Address - Country:US
Mailing Address - Phone:559-784-5127
Mailing Address - Fax:
Practice Address - Street 1:524 W PUTNAM AVE
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-3274
Practice Address - Country:US
Practice Address - Phone:559-784-5127
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10864T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD004930Medicaid
CADE4606OtherRAILROAD MEDICARE
CADE4606OtherRAILROAD MEDICARE
CAZZZ035792Medicare PIN