Healthcare Provider Details

I. General information

NPI: 1831131150
Provider Name (Legal Business Name): IRINA GROMOV MD, PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 10/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8222 DOUGLAS AVE
DALLAS TX
75225-5923
US

IV. Provider business mailing address

8222 DOUGLAS AVE STE 375
DALLAS TX
75225-5973
US

V. Phone/Fax

Practice location:
  • Phone: 214-905-5090
  • Fax:
Mailing address:
  • Phone: 214-905-5090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberL4407
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberL4407
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: