1801870449 NPI number — SUNTI S. SRIVATHANAKUL MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801870449 NPI number — SUNTI S. SRIVATHANAKUL MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

SRIVATHANAKUL

Provider First Name:

SUNTI

Provider Middle Name:

S.

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1801870449

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

01/23/2013

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 660599

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

DALLAS

Provider Business Mailing Address State Name:

TX

Provider Business Mailing Address Postal Code:

75266-0599

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

9202 ELAM RD

Provider Second Line Business Practice Location Address:

SOUTHEAST DALLAS HEALTH CENTER

Provider Business Practice Location Address City Name:

DALLAS

Provider Business Practice Location Address State Name:

TX

Provider Business Practice Location Address Postal Code:

75217-4151

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

214-266-1600

Provider Business Practice Location Address Fax Number:

214-266-1742

Provider Enumeration Date:

12/06/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207Q00000X , with the licence number:  J8783 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 161686405 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 161686407 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 161686408 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 161686412 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 161686409 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 161686401 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 161686411 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 161686403 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 161686404 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 84Y442 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 161686402 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 161686406 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 161686410 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".