Provider Demographics
NPI:1801870449
Name:SRIVATHANAKUL, SUNTI S (MD)
Entity type:Individual
Prefix:
First Name:SUNTI
Middle Name:S
Last Name:SRIVATHANAKUL
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 660599
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0599
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9202 ELAM RD
Practice Address - Street 2:SOUTHEAST DALLAS HEALTH CENTER
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75217-4151
Practice Address - Country:US
Practice Address - Phone:214-266-1600
Practice Address - Fax:214-266-1742
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8783207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX161686405Medicaid
TX161686407Medicaid
TX161686408Medicaid
TX161686412Medicaid
TX161686409Medicaid
TX161686401Medicaid
TX161686411Medicaid
TX161686403Medicaid
TX161686404Medicaid
TX84Y442OtherBLUE CROSS BLUE SHIELD
TX161686402Medicaid
TX161686406Medicaid
TX161686410Medicaid
TX161686411Medicaid
TX161686402Medicaid