Healthcare Provider Details

I. General information

NPI: 1033429253
Provider Name (Legal Business Name): WIRACHIN HOONPONGSIMANONT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2010
Last Update Date: 05/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 THE CITY DR S
ORANGE CA
92868-3201
US

IV. Provider business mailing address

59 GARDENHOUSE WAY
IRVINE CA
92620-3373
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-5705
  • Fax:
Mailing address:
  • Phone: 862-216-0466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA114539
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: