1033241930 NPI number — JOHN RUSSELL SORDEAN OMD LAC ND

Table of content: JOHN RUSSELL SORDEAN OMD LAC ND (NPI 1033241930)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033241930 NPI number — JOHN RUSSELL SORDEAN OMD LAC ND

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SORDEAN
Provider First Name:
JOHN
Provider Middle Name:
RUSSELL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OMD LAC ND
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SORDEAN
Provider Other First Name:
JAY
Provider Other Middle Name:
R
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OMD LAC ND
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1033241930
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/04/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3998
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BERKELEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-220-2568
Provider Business Mailing Address Fax Number:
510-849-1176

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1720 BANCROFT WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERKELEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-849-1176
Provider Business Practice Location Address Fax Number:
510-849-1230
Provider Enumeration Date:
03/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  AC2239 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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