Provider Demographics
NPI:1558628552
Name:WUNGWATTANA, MINKKWAN (MD)
Entity Type:Individual
Prefix:
First Name:MINKKWAN
Middle Name:
Last Name:WUNGWATTANA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 W LA VETA AVE
Mailing Address - Street 2:CS HOSPITALIST
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4203
Mailing Address - Country:US
Mailing Address - Phone:714-509-8826
Mailing Address - Fax:714-509-4169
Practice Address - Street 1:1201 W LA VETA AVE
Practice Address - Street 2:PSF HOSPITALIST DIVISION
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4203
Practice Address - Country:US
Practice Address - Phone:714-509-8644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-13
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA128717208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics