Basic Information
| Provider Information | |||||||||
| NPI: | 1346291564 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WANGSANUTR | ||||||||
| FirstName: | SAMA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 775 | ||||||||
| Address2: | |||||||||
| City: | GARDEN GROVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928420775 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146360242 | ||||||||
| FaxNumber: | 7146360391 | ||||||||
| Practice Location | |||||||||
| Address1: | 12900A GARDEN GROVE BLVD | ||||||||
| Address2: | #122 | ||||||||
| City: | GARDEN GROVE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146360342 | ||||||||
| FaxNumber: | 7146360391 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 09/30/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | A30627 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | OOA306270 | 05 | CA | MEDICAID |