Provider Demographics
NPI:1912127127
Name:SRIVATHANAKUL, SURAPHANDHU (MD)
Entity Type:Individual
Prefix:DR
First Name:SURAPHANDHU
Middle Name:
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 1:2630 N FITZHUGH AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-3366
Mailing Address - Country:US
Mailing Address - Phone:214-826-6420
Mailing Address - Fax:214-826-6739
Practice Address - Street 1:2630 N FITZHUGH AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-3366
Practice Address - Country:US
Practice Address - Phone:214-826-6420
Practice Address - Fax:214-826-6739
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-27
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE7288174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1202772-01Medicaid
TX1202772-01Medicaid