Provider Demographics
NPI:1306097084
Name:ORAVIVATTANAKUL, SRIVADEE (MD)
Entity type:Individual
Prefix:
First Name:SRIVADEE
Middle Name:
Last Name:ORAVIVATTANAKUL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 PANTHER LN
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-4879
Mailing Address - Country:US
Mailing Address - Phone:612-423-6261
Mailing Address - Fax:
Practice Address - Street 1:907 PANTHER LN
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-4879
Practice Address - Country:US
Practice Address - Phone:612-423-6261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-01
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01086134A2084N0400X
FLME1438862084N0400X
NJ25MA111518002084N0400X
WI75834-202084N0400X
TXT11702084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology