Provider Demographics
NPI:1346291564
Name:WANGSANUTR, SAMA (MD)
Entity Type:Individual
Prefix:
First Name:SAMA
Middle Name:
Last Name:WANGSANUTR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 775
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92842-0775
Mailing Address - Country:US
Mailing Address - Phone:714-636-0242
Mailing Address - Fax:714-636-0391
Practice Address - Street 1:12900A GARDEN GROVE BLVD
Practice Address - Street 2:#122
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843
Practice Address - Country:US
Practice Address - Phone:714-636-0342
Practice Address - Fax:714-636-0391
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30627207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOA306270Medicaid
CAA30627Medicare ID - Type Unspecified
CAOOA306270Medicaid