Provider Demographics
NPI:1679577258
Name:SORAH, DARRELL ALLEN JR (OD)
Entity type:Individual
Prefix:DR
First Name:DARRELL
Middle Name:ALLEN
Last Name:SORAH
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:P O BOX 608
Mailing Address - Street 2:
Mailing Address - City:WINDER
Mailing Address - State:GA
Mailing Address - Zip Code:30680-0608
Mailing Address - Country:US
Mailing Address - Phone:770-867-2505
Mailing Address - Fax:770-867-8668
Practice Address - Street 1:90 CHURCH ST
Practice Address - Street 2:
Practice Address - City:WINDER
Practice Address - State:GA
Practice Address - Zip Code:30680-1714
Practice Address - Country:US
Practice Address - Phone:770-867-2505
Practice Address - Fax:770-867-8668
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1513152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0590190001Medicare NSC
GAU58590Medicare UPIN