MEDICARE: DR. PORNTHEP WATTANAMANO MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	C186338	CA
2	207RI0200X	Infectious Disease Physician	C186338	CA
3	207RI0200X	Infectious Disease Physician	L5950	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00193508	OTHER	TX	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	8R0570	OTHER	TX	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1295738516
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PORNTHEP WATTANAMANO MD

Provider Business Mailing Address
First Line	:	3335 RIVIERA DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-6614
Country	:	US
Telephone Number	:	713-384-3229
Fax Number	:

Provider Business Practice Location Address
First Line	:	3335 RIVIERA DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-6614
Country	:	US
Telephone Number	:	713-384-3229
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	09/29/2023

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