Provider Demographics
NPI:1497755581
Name:SRIDAROMONT, SOMKID (MD)
Entity Type:Individual
Prefix:
First Name:SOMKID
Middle Name:
Last Name:SRIDAROMONT
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 1:3702 20TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1206
Mailing Address - Country:US
Mailing Address - Phone:806-791-5930
Mailing Address - Fax:806-791-5937
Practice Address - Street 1:3702 20TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1206
Practice Address - Country:US
Practice Address - Phone:806-791-5930
Practice Address - Fax:806-791-5937
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2014-02-13
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
TXE52552080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX034659501Medicaid
TX89773ZOtherBCBS
TX00L84YMedicare ID - Type Unspecified
TX034659501Medicaid