Basic Information
| Provider Information | |||||||||
| NPI: | 1881018703 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SORATHIA | ||||||||
| FirstName: | SUFIAN | ||||||||
| MiddleName: | JABBAR | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4800 BELFORT RD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322566004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043987205 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3635 CLYDE MORRIS BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | PORT ORANGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321292349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867881242 | ||||||||
| FaxNumber: | 3867568802 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2014 | ||||||||
| LastUpdateDate: | 01/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | ME130655 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 108374600 | 05 | FL | MEDICAID |