Provider Demographics
NPI:1407073216
Name:SOMYREDDY, KISHORI VENKATA LAXMI (MD)
Entity Type:Individual
Prefix:DR
First Name:KISHORI
Middle Name:VENKATA LAXMI
Last Name:SOMYREDDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 COTTONWOOD LN STE 205
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-6111
Mailing Address - Country:US
Mailing Address - Phone:214-727-8900
Mailing Address - Fax:
Practice Address - Street 1:1110 COTTONWOOD LN STE 205
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-6111
Practice Address - Country:US
Practice Address - Phone:214-727-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH148522084N0400X
TXR9692174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30209662Medicaid
NH001666201Medicare PIN