Healthcare Provider Details

I. General information

NPI: 1871191684
Provider Name (Legal Business Name): SRI KANTH DOMMETI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2020
Last Update Date: 08/24/2022
Certification Date: 08/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ROSE ST
LEXINGTON KY
40536-3901
US

IV. Provider business mailing address

7403 WURZBACH RD APT 348
SAN ANTONIO TX
78229-3841
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-2222
  • Fax: 859-323-5090
Mailing address:
  • Phone: 210-993-6387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberBP10072981
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberBP10072981
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number56627
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: