Provider Demographics
NPI:1720242126
Name:SOPONTAMMARAK, SOMKIAT (MD)
Entity type:Individual
Prefix:DR
First Name:SOMKIAT
Middle Name:
Last Name:SOPONTAMMARAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4503 82ND PL
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-4239
Mailing Address - Country:US
Mailing Address - Phone:806-441-1257
Mailing Address - Fax:325-200-4498
Practice Address - Street 1:6401 INDIANA AVE
Practice Address - Street 2:SUITE C
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79413-5740
Practice Address - Country:US
Practice Address - Phone:806-799-3322
Practice Address - Fax:806-799-3327
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-15
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN93042080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6702120Medicaid
TXTXB125279OtherTX MEDICARE INDIVIDUAL PTAN
SD6702120Medicaid