Provider Demographics
NPI:1972560498
Name:SORIANO, CLINTON REYES (MD)
Entity type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:REYES
Last Name:SORIANO
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 1:1901 S HAWTHORNE RD
Mailing Address - Street 2:SUITE 340
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3921
Mailing Address - Country:US
Mailing Address - Phone:336-765-6277
Mailing Address - Fax:336-659-0449
Practice Address - Street 1:1901 S HAWTHORNE RD
Practice Address - Street 2:SUITE 340
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3921
Practice Address - Country:US
Practice Address - Phone:336-765-6277
Practice Address - Fax:336-659-0449
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22056208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
4136089OtherAETNA
NC8978420Medicaid
NC201919Medicare ID - Type Unspecified
NC8978420Medicaid