Provider Demographics
NPI:1003819426
Name:SORY, W CRYSUP (MD)
Entity Type:Individual
Prefix:
First Name:W
Middle Name:CRYSUP
Last Name:SORY
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:PO BOX 740608
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75374-0608
Mailing Address - Country:US
Mailing Address - Phone:469-317-9900
Mailing Address - Fax:
Practice Address - Street 1:12700 PARK CENTRAL DR
Practice Address - Street 2:STE 430
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75251-1527
Practice Address - Country:US
Practice Address - Phone:972-239-8902
Practice Address - Fax:972-661-2551
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF45522085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138214501Medicaid
TX83R758Medicare ID - Type Unspecified
TX138214501Medicaid