Basic Information
| Provider Information | |||||||||
| NPI: | 1306976733 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SRISINROONGRUANG | ||||||||
| FirstName: | RATTAPOL | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 960160 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731960160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8884472450 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 800 W RANDOL MILL RD | ||||||||
| Address2: | DEPT OF EMERGENCY MEDICINE | ||||||||
| City: | ARLINGTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760122504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8175486100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 02/03/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 07/17/2007 | ||||||||
| NPIReactivationDate: | 05/02/2008 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | C70003449 | DE | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | N4124 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00778778 | 01 | TX | RAILROAD MCARE THRU AEMA | OTHER | 204229301 | 05 | TX | MEDICAID | 8BT332 | 01 | TX | BCBS TX | OTHER | 204229302 | 05 | TX | MEDICAID |