Provider Demographics
NPI:1245264639
Name:WONGWORAWAT, AMNART A (MD)
Entity type:Individual
Prefix:
First Name:AMNART
Middle Name:A
Last Name:WONGWORAWAT
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 1:41715 WINCHESTER RD
Mailing Address - Street 2:SUITE #201A
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-4808
Mailing Address - Country:US
Mailing Address - Phone:951-699-9201
Mailing Address - Fax:951-699-9205
Practice Address - Street 1:41715 WINCHESTER RD
Practice Address - Street 2:SUITE #201A
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-4808
Practice Address - Country:US
Practice Address - Phone:951-699-9201
Practice Address - Fax:951-699-9205
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA74446208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A744460Medicaid
I35535Medicare UPIN
CA00A744460Medicaid