Provider Demographics
NPI:1710903513
Name:ROMANELLI, ENID SAMARA (MD)
Entity Type:Individual
Prefix:DR
First Name:ENID
Middle Name:SAMARA
Last Name:ROMANELLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1141 KINWEST PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-0100
Mailing Address - Country:US
Mailing Address - Phone:214-239-2222
Mailing Address - Fax:214-239-2223
Practice Address - Street 1:1141 KINWEST PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-0100
Practice Address - Country:US
Practice Address - Phone:214-239-2222
Practice Address - Fax:214-239-2223
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9890207R00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146657504Medicaid
TX00610WMedicare ID - Type UnspecifiedMEDICARE #
TXH19142Medicare UPIN