Basic Information
| Provider Information | |||||||||
| NPI: | 1740665553 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHARIYAWONG | ||||||||
| FirstName: | PHUMPATTRA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 61160 | ||||||||
| Address2: | |||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784661160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3618842904 | ||||||||
| FaxNumber: | 3618570572 | ||||||||
| Practice Location | |||||||||
| Address1: | 3315 S ALAMEDA ST | ||||||||
| Address2: | |||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 784111820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8773324602 | ||||||||
| FaxNumber: | 3618570572 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2015 | ||||||||
| LastUpdateDate: | 12/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | T3600 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | T3600 | 01 | TX | TEXAS MEDICAL BOARD | OTHER |