Provider Demographics
NPI:1831131150
Name:GROMOV, IRINA (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:IRINA
Middle Name:
Last Name:GROMOV
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8222 DOUGLAS AVE STE 375
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75225-5973
Mailing Address - Country:US
Mailing Address - Phone:214-905-5090
Mailing Address - Fax:
Practice Address - Street 1:8222 DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75225-5923
Practice Address - Country:US
Practice Address - Phone:214-905-5090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL44072084P0802X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH84310Medicare UPIN