Healthcare Provider Details

I. General information

NPI: 1609010271
Provider Name (Legal Business Name): SOKPHEARY SRORN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2009
Last Update Date: 02/08/2022
Certification Date: 02/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7190 CRESTWOOD BLVD KAISER PERMANENTE FREDERICK MEDICAL CENTER
FREDERICK MD
21703-7314
US

IV. Provider business mailing address

7190 CRESTWOOD BLVD KAISER PERMANENTE FREDERICK MEDICAL CENTER
FREDERICK MD
21703-7314
US

V. Phone/Fax

Practice location:
  • Phone: 800-777-7904
  • Fax:
Mailing address:
  • Phone: 800-777-7904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101253049
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0074996
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: