Healthcare Provider Details

I. General information

NPI: 1346291564
Provider Name (Legal Business Name): SAMA WANGSANUTR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 09/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12900A GARDEN GROVE BLVD #122
GARDEN GROVE CA
92843
US

IV. Provider business mailing address

PO BOX 775
GARDEN GROVE CA
92842-0775
US

V. Phone/Fax

Practice location:
  • Phone: 714-636-0342
  • Fax: 714-636-0391
Mailing address:
  • Phone: 714-636-0242
  • Fax: 714-636-0391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA30627
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: