Provider Demographics
NPI:1043703564
Name:MAKPAIBOONVATANA, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:MAKPAIBOONVATANA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1909 N WATERMAN AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-4842
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1909 N WATERMAN AVE STE 3
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404
Practice Address - Country:US
Practice Address - Phone:909-882-8883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-09
Last Update Date:2021-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33980TLG152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist